V 


'i^A 


IMAGE  EVALUATION 
TEST  TARGET  (MT-S) 


m 


'^o 


4j 


'<^r 


y 


i' 


1.0 


I.I 


111 

■  50 

u 
u    ^ 


1^  m 

2    ,u„22 
2.0 


1.8 


1.25  j|u 

1^ 

< 6"     — 

^ 

HiotDgraphic 

Sdences 

Corporation 


23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

(716)  872-4503 


J 


\ 


i\^ 


^ 

^ 
« 


rv 


6^ 


CIHM/ICMH 

Microfiche 

Series. 


CIHM/ICMH 
Collection  de 
microfiches. 


0 


Canadian  Institute  for  Historical  Microreproductions  /  Institut  ?anadien  de  microreproductions  historiques 


i'timm.. 


Technical  and  Bibliographic  Notes/Notes  techniques  et  bibliographiques 


The  Institute  has  attempted  to  obtain  the  best 
original  copy  available  for  filming.  Features  of  this 
copy  which  may  be  bibliographically  unique, 
which  may  alter  any  of  the  images  in  the 
reproduction,  or  which  may  significantly  change 
the  usual  method  of  filming,  are  checked  below. 


L'Institut  a  microfilm*  le  meilleur  exemplaire 
qu'il  lui  a  6t6  possible  de  se  procurer.  Les  details 
de  cet  exemplaire  qui  sont  peut-dtre  uniques  du 
point  de  vue  bibliographique,  qui  peuvent  modifier 
une  image  reproduite,  ou  qui  peuvent  exiger  une 
modification  dans  la  mdthode  normale  de  filmage 
sont  indiquds  ci-dessous. 


D 
D 
D 


I — I    Coloured  maps/ 


Coloured  covers/ 
Couverture  de  couleur 

Covers  damaged/ 
Couverture  endommagde 

Covers  restored  and/or  laminated/ 
Couverture  restaur6e  et/ou  pelliculde 

Cover  title  missing/ 

Le  titre  de  couverture  manque 


D 
D 
D 
D 


D 


Cartes  gdographiques  en  couleur 

Coloured  ink  (i.e.  other  than  blue  or  black)/ 
Encre  de  couleur  (i.e.  autre  que  bleue  ou  noire) 

Coloured  plates  and/or  illustrations/ 
Planches  et/ou  illustrations  en  couleur 

Bound  with  other  material/ 
Relid  avec  d'autres  documents 

Tight  binding  may  c&use  shadows  or  distortion 
along  interior  margin/ 

La  reliure  serr6e  peut  causer  de  I'ombre  ou  de  la 
distortion  le  long  de  la  marge  intdrieure 

Blank  leaves  added  during  restoration  may 
appear  within  the  text.  Whenever  possible,  these 
have  been  omitted  from  filming/ 
11  se  peut  que  certaines  pages  blanches  ajout6es 
lors  d'une  restauration  apparaissent  dans  le  texte, 
mais,  lorsque  cela  6tait  possible,  ces  pages  n'ont 
pas  6t6  film6es. 


D 
D 
D 
D 
D 
D 
D 
D 


Coloured  pages/ 
Pages  de  couleur 

Pages  damaged/ 
Pages  endommagdes 

Pages  restored  and/or  laminated/ 
Pages  restaurdes  et/ou  pellicul6es 

Pages  discoloured,  stained  or  foxed/ 
Pages  d6color6es,  tachetdes  ou  piqudes 

Pages  detached/ 
Pages  d§tachdes 

Showthrough/ 
Transparence 

Quality  of  print  varies/ 
Quality  in^gale  de  I'impression 

Includes  supplementary  material/ 
Comprend  du  matdriel  suppl^mentaire 

Only  edition  available/ 
Seule  Edition  disponible 

Pages  wholly  or  partially  obscured  by  errata 
slips,  tissues,  etc.,  have  been  refilmed  to 
ensure  the  best  possible  image/ 
Les  pages  totalement  ou  partiellement 
obscurcies  par  un  feuillet  d'errata,  une  pelure, 
etc.,  cnt  6t6  filmdes  d  nouveau  de  fapon  d 
obtenir  la  meilleure  image  possible. 


Si- 


D 


Additional  comments:/ 
Commentaires  suppl6mentaires: 


This  Item  is  filmed  at  the  reduction  relio  4;hecked  below/ 

Ce  document  est  film6  au  taux  de  reduction  indiqud  ci-dessous. 


10X 

14X 

18X 

22X 

26X 

30X 

i^^"n 

' 

t 

□ 

^■^ 

i9y 

^^^ 

^^"^^ 

1RX 

2DX 

%^ 

28X 

32X 

*-i3ii4»;>,e'i^iinoi'ri.^'.;peSi'j*^^'C-5.'^^ 


re 

I6tails 
}s  du 
nodifier 
)r  une 
ilmage 


The  copy  filmed  here  has  been  reproduced  thanks 
to  the  generosity  of: 

Library  of  Congress 
Photoduplication  Service 

The  images  appearing  here  are  the  best  quality 
possible  considering  the  condition  and  legibility 
of  the  original  copy  and  in  keeping  with  the 
filming  contract  specifications. 


L'exemplaire  film*  fut  reproduit  grAce  d  la 
gAnArositA  de: 

Library  of  Congress 
Photoduplication  Service 

Les  images  suivantes  ont  AtA  reproduites  avec  le 
plus  grand  soin,  compte  tenu  de  la  condition  et 
de  la  nettetA  de  l'exemplaire  film*,  et  en 
conformity  avec  les  conditions  du  contrat  de 
fllmage. 


ies 


e 


/  errata 
id  to 

It 

ie  pelure, 

pon  d 


Original  copies  in  printed  paper  covers  are  filmed 
beginning  with  the  front  cover  and  ending  on 
the  last  page  with  a  printed  or  illustrated  Impres- 
sion, or  the  back  cover  when  appropriate.  All 
other  original  copies  are  filmed  beginning  on  the 
first  page  with  a  printed  or  illustrated  impres- 
sion, and  ending  on  the  last  page  with  a  printed 
or  illustrated  impression. 


The  last  recorded  frame  on  each  microfiche 
shall  contain  the  symbol  -^(meaning  "CON- 
TINUED"), or  the  symbol  V  (meaning  "END"), 
whichever  applies. 

Maps,  plates,  charts,  etc.,  may  be  filmed  at 
different  reduction  ratios.  Those  too  large  to  be 
entirely  included  in  one  exposure  are  filmed 
beginning  in  the  upper  left  hand  corner,  left  to 
right  and  top  to  bottom,  as  many  frames  as 
required.  The  following  diagrams  illustrate  the 
method: 


1 

2 

3 

Les  exemplaires  originaux  dont  la  couverture  en 
papier  est  ImprimAe  sont  filmAs  en  commengant 
par  le  premier  plat  et  en  terminant  soit  par  la 
dernlAre  page  qui  comporte  une  empreinte 
d'impression  ou  d'illustration,  soit  par  le  second 
plat,  salon  le  cas.  Tous  les  autres  exenipfsires 
originaux  sont  filmis  en  commengant  par  la 
premiAre  page  qui  comporte  une  empreinte 
d'impression  ou  d'illustration  et  en  terminant  par 
la  dernlAro  page  qui  comporte  une  telle 
empreinte, 

Un  des  symboles  suivants  apparaitra  sur  la 
derniAre  image  de  cheque  microfiche,  selon  le 
cas:  le  symbole  — ►  signifie  "A  SUIVRE  ",  le 
symbole  y  signifie  "FIN". 

Les  cartes,  planches,  tableaux,  etc.,  peuvent  Atre 
filmAs  A  des  taux  de  reduction  diffArents. 
Lorsque  le  document  est  trop  grand  pour  Atre 
reproduit  en  un  seul  cllchA,  il  est  filmA  A  partir 
de  Tangle  supArieur  gauche,  de  gauche  A  droite, 
et  de  haut  en  bas,  en  prenant  le  nombre 
d'Images  nAcessaire.  lies  diagrammes  suivants 
illustrent  la  mAthode. 


32X 


1 

2 

3 

4 

5 

6 

m»'- 


,1 


HO 

Has  I 
when 
coinm 
is  well 
Ii 

D 
univers 
used  it 

D 
cases  ol 
prostra 
benefit. 

D 
with  de 
convey 
relieved 
of  mind 

Di 
able  hel 

Di 
insom^ 

Di 

it  in  pfa 
with  the 

Sen 
furnishe 
charges. 

Pre 


B 

CAVTH 


CONSUMPTION. 


HORSFORD'S  ACI D  PHOSPHATE 

Has  been  used  with  good  effect  in  consumption,  and  also 
when  complicated  with  indigestion.  In  night  sweats  it  has 
commonly  given  speedy  benefit.  It  is  agreeable  to  the  taste 
IS  well  tolerated,  and  does  not  constipate  the  bowels. 

Indicated  in  all  wasting  and  debilitating  diseases. 

Dr.  J.  A.  Meek,  Glencoe,  Minn  ,  says:  "It  seems  to  be  almon 
universally  useful  when  there  is  a  tendency  to  tubercle.  I  have  also 
used  it  to  great  advantage  in  a  diversity  of  cases  of  defective  nutrition  " 

Dr.  F.  C.  Hawley  Canandaigua.  N.  Y.,  says:  "  I  have  used  it  in 
cases  of  phthisis  and  inflammation  of  the  lungs,  where  there  was  great 
prostration,  constant  cough  and  profuse  expectoration,  with  marked 
benefit. 

.  u  P'\7'^  **-j^-  Davison  Parsons,  Kan.,  says:  "I  have  used  it 
with  decided  and  certain  benefit  in  consumption.  I  do  not  intend  to 
convey  the  impression  that  I  have  cured  consumption  with  it,  but  it  has 
relieved  its  distressing  symptoms,  such  as  iowness  of  spirits  weakness 
of  mind  and  body,  nervous  irriution,"  etc. 

...    Pi  ^■,  Thompson,  Lowell.  Mass  .  says:    "I  have  found  it  a  valu- 
able helper  in  nervous  debility  and  incipient  consumption  " 

Dr.  Thos.  Phillips.  Austin.  Minn.,  says:  "  I  have  used  it  in  the 
msomaia  of  phthisis  pulmonahs,  with  immediate  good. " 

w  .  >^;J-."-  ^/!?u^;.^*"'!  ^r""*'  '^'='» .  "ys:  ••  I  always  prescribe 
it  In  phthisis  and  debility,  physical  or  nervous,  and  have  been  pleased 
with  the  results  obuined."  ^  ^<^^^ 


Send  for  descriptive  circular.     Physicians  who  wish  to  test  it  will  be 
furnished    a  bottle  on  application,   without  expense,   except    express 

Prepared  under  the  direction  of  Prof.  E.  N.  Horsford,  by  the 

EUMFOED  CHEMICAL  WOBKS,  Providence,  B.  I. 
Beware  of  Substitutes  and  Imitations. 

CAVTIOir.-Be  sure  the  word  "  Hartford's  "  is  Printed  on  the  label. 
All  others  are  spurious.     Jfever  sold  in  bulk.  "'•'"• 


"^ 


penMHUMHR 


liHHHIII 


ma-    — '■ 


''.' 


r 


I 


i 


N 


SLEEP, 


INSOMNIA,  AND  HYPNOTICS. 


'if 


E.  P:  HURD,  M.  D.. 


Member  of  the  Massachusetts   Medical  Society;    Member  of  the 

Cliinatoh\^ical  Society;  Memlter  of  the  Soci^t/  lie  M^tie- 

ciiie    Pratiijue    (Paris,    France);    one    of   the 

Physicians  to  the  Anna  Jaqiies   Hos- 

f'ital,    .Yew/iuryport,    Mass. 


^iffi  /^. 


/ 


1891. 
GEORGE  S.  DAVIS 

DETROIT,   MICH. 


f— _^ 


■Imiiiiw 


"^'^ 


■^^ 


vVO 


(. 


.^\ 


Copyrighted  by 

GEORGE  8.  DAVIS. 

1801. 


c 


^^ 


,V^^ 


TABLE  OF  CONTENTS. 


CHAPTER   I. 

TMK    l'IIYSI()I.O(;V   OK   SI.EKP, 


Page . 


General  Considerations  on  Sleep— The  Necessity  of 
Sleep;  Proximate  Cause  or  Causes— Functions  of 
the  Cerebrum  —  Registration  of  Impressions- 
Partial  Memories;  Sensory  and  Motor  Localiza- 
tions—The Cerebrum  as  an  Originator  of  Energy 
—Fatigue  under  Exertion— Waste  and  Repair- 
Antecedents  of  Sleep— State  of  the  Circulation 
During  Sleep— The  Sense  of  Fatigue— Predis- 
posing Causes  of  Sleep— Amount  of  Sleep  Nec- 
essary—Dreams— Dreaming  an  Indication  of  Im- 
perfect Sleep;  often  a  Morbid  Symptom 1-28 

CHAPTER  II. 

INSOMNIA. 

General  Divisions:  i,  Psychical;  2,  Physical  Causes 
—Pain  as  a  Cause  of  Insomnia — In:^omnia  Due 
to  Overwork  of  the  Brain -Treaiment— Insomnia 
Due  to  Morbid  States  of  the  Brain— Insomnia  of 
Respiratory  Origin— Insomnia  of  Heart  Disease 
— Cardiac  Dyspnoea— Insomnia  of  Gastro-intesti- 
nal  Origin— Insomnia  of  Cystitis  —  Insomnia 
from  Genital  Irritation  —  Insomnia  of  Toxic 
Origin— Insomnia  of  Continued  Fevers  and  Its 
Treatment 20-88 


r*- 


■% 


VI, 


CHAPTER  Ml. 


IIVI'NOTK  S. 

Opium  and  Narcotics-Alcohol  and  Other  StimuhuUs 
—Bromide  of  Potassium  and  Bromides— Chloral 
-Sulphonal  -  Paraldehyd  -  L'rcthan  -  Somnal 
-Amylen  hydrate  —  Chloralamid  —  Remeduil 
Measures  not'  Medicinal;  (a)  Baths,  (b)  The  Wet 
Pack,  (c)  The  Turkish  Bath,  (d)  Shower  and  J?t- 
baths,  (e)  Electricity 


Page. 


S(j-II2 


il- 


PREFACE. 


'age. 


ij-iia 


This  little  treatise,  though  Ihiik;  advertised  Id  he  a  trans- 
lation of  a  recent  mnnoxraph  of  Germain  S4e  i"  the  MMrim 
A/<i(/iini-.  is  in  reality  a  product  of  inyown  pen,  and  whatever 
merit  may  helonjj  to  it,  and  all  the  faults  and  mistakes,  must 
he  credited  to  me.  The  monograph  of  Prof.  See,  with  all  Its 
excellences,  was  found  to  he  too  brief  ami  too  Incomplete  for 
reproduction  in  the  Leisure  Library.  A  book  on  the  subject 
had  been  promised,  and  the  title  announced,  and  I  felt  con- 
strained to  make  ^ood  the  announcement  by  my  own  en- 
deavors; and  all  that  I  can  say  in  palliation  of  my  pre- 
sumption in  attempting  to  write  a  treatise  on  a  subject  which 
has  been  recently  handled  so  ably  by  Macfarlane,  is  that  the 
topic  \%  one  that  has  intensely  interested  me,  that  I  have 
bestowed  on  it  considerable  independent  thought,  and  that  I 
have  endeavored  concisely  to  state,  in  a  common  sense  and 
practical  way,  the  questions  presented.  It  will  be  found, 
moreover,  that  as  long  as  medical  subjects  continue  to 
attract  the  attention  of  mankind,  so  long  will  there  be  trea- 
tises written  on  Sleep  and  its  phenomena,  and  attempts, 
scientifically,  to  explain  these  phenomena  and  remedy  those 
conditions  which  give  rise  to  thai  distressing  intitmity  of  our 
modern  life — Insomnia. 

I  desire  in  this  place  to  stale,  once  for  all,  thai  any 
coincidences  between  parts  of  this  treatise  and  articles  which 
have  appeared  during  the  past  year  in  certain  medical  jour- 
n-ils  (the  Therapeutic  Gazette,  the  Boston  Medical  and  Sur- 
gical Journal,  the  Medical  Age)  are  explained  by  the  fact 
that,  in  the  preparation  of  this  book,  I  have  used  material 
which  I  had  previously  contributed  to  the  columns  of  those 
journals. 

E.  P.  Hi)Ki>,  M.D. 

Newburyport,  Mass.,  Dec.  1st,  1S91. 


i' 


o 


CHAPTER  I. 

THE  PHYSIOLOGY  OF  SLEEP, 

It  has  been  sufficiently  demonstrated  that  during 
sleep  the  brain  is  relatively  an.x«mic.  The  observa- 
tions of  Durham,  of  Hammond,  of  Mosso,  and  others, 
have  proved  this.  During  sleep,  all  the  encephalic 
blood-vessels  are  under  a  diminished  pressure,  as 
shown  by  the  manometer.  And  this  lessening  of  the 
active  flow  corresponds  with  a  diminution  of  cerebral 
function.  This  is  in  accordance  with  the  facts  of 
physiology  generally:  the  performance  of  function  is 
characterized  by  vascular  fulness  and  activity;  the 
cessation  of  function  is  attended  with  decrease  of  the 
vascularity  and  volume  of  a  part. 

The  immediate  cause  of  sleep,  however,  is  not 
simply  the  shutting  off  of  a  portion  of  the  blood-current 
from  the  brain.  The  lessening  of  the  blood-supply  is 
rather  the  accompaniment  than  the  cause  of  sleep. 
The  true  cause  is  the  ionpor—e ngourdissement—oi  the 
cerebral  cells.  This  torpor  may  be  the  result  of 
waste,  unbalanced  by  repair,  of  the  hemispherical 
ganglia,  which  become  functionally  inactive  owing 
to  diminution  of  oxidizing  material,  as  well  as  to 
clogging  of  the  venous  and  lymphatic  channels  by  the 
accumulated  debris  of  organic  combustions. 

But  this  is  not  all.  As  the  effete  products  of  cell 
function  have  a  paralyzing  action  on  the  cells  them- 
selves—a truth  exemplified  even  in  the  protoplasmic 


^mmmmmmmmm 


SHcnmoMMaM 


-:!-^«l  . 


,„.  o.  microbe,  whic.  a,e  now  ---"X^^l'^ 
Prever   has  much   probability  in  its  favor     Preyer 

and  refers  to  e  v  ^___^,^  ^„j  produced  a 

llTomno,",' condition  which  was  nndistinguish- 
abe^fomata,  Sleep,    But  .actic  acid  is  on  y  one  o 

the  toxic  product.  o<  the  ''^f  .X^^^ter™    U 
=Alu  are  also  destructive  o!  cell  life,  ana  every 

rE-rrtrva:rpT-,^^^^^^^^^^ 

ratffl:je.«ndsthat^^^^^^^^^^^^ 
::r;:tr  tCTro^Ss  narcosis,  while  the  iatter 

''""^"''"^.rL^nt^ir.r/ror:ChtHT;r 
:r=rrursir:^.  Znd  th.  .cumulation 

1  ^o  h<-raiise  the  ehmination  ot  tnese  s.uu 
takes  place  because  uic 
stances  by  the  urine  goes  on  the  more  slowly 

*LaMidecine  Modcrne,  1890,  p.  183- 


■■•'  ft  ^ 


ceby 
J— so 
i   by 
reyer 
waste 
sleep, 
:  acid 
ced  a 
guish- 
ane  of 
rinary 
ry  cell 
1  exer- 
oon  as 
:o  per- 
ho  has 
inimals 
;al  and 
ay  pos- 
e  night, 
e  latter 

drawn 
recesses 
by  their 
nulation 
ese  sub- 
»wly  the 


—  3  — 
nearer  we  approach  the  usual  period  of  sleep.     On 
the  other  hand,  during  sleep,  the  convulsivant  sub- 
stances which  result  from  denutrition  cooperate  in 
bringing  about  awakening.f 

In  accordance  with  this  theory,  it  might  be  expected 
that  there  would  be  a  definite  relationship  between  the  labor 
done  and  the  amount  of  sleep  required— that  hard  brain 
work  would  necessitate  more  sleep  than  muscular  work,  and 
that  those  who  toil  little  would  sleep  little.  Unfortunately, 
theories,  like  parables,  do  not  always  "go  on  all  fours." 
The  relationship  above  spoken  of  is  not  mathematically 
established;  the  coal-heavers  and  diggers  of  the  soil  are  the 
best,  while  the  brain-workers  are  the  poorest  sleepers,  and 
those  that  do  little  or  no  work  of  brain  or  muscle  sometimes 
sleep  with  extraordinary  soundness,  and  even  have  no  diffi- 
culty in  going  to  sleep  in  the  daytime. 

There  is  reason  to  believe  that  sleep  often  ensues  from 
simple  torpor  or  lethargy  of  the  cerebral  cells,  a  state  into 
which  some  persons  are  constitutionally  prone  to  lapse. 
The  state  of  the  foetus  in  utero  may  be  regarded  as  one  of 
continuous  sleep,  and  it  has  been  remarked  that  idiots  and 
feeble-minded  persons  sleep  much  more  than  active-minded 
men. 

The  Necessity  of  Sleep. — It  is  a  law  of 
nature  that  every  kind  of  force  or  energy  emanat- 
ing from  the  organic  or  inorganic  world  shall  be 
the  exact  equivalent  of  some  pre-existent  kind  of 
force.  This  is  the  doctrine  of  the  correlation  and 
equivalence  and  persistence  of  force  now  universally 
admitted.     The  power  that  drives,  the  piston  rod  of 

+  G.  S6e,  /oc  cit. 


—  4  — 
the  steam  engine  existed  latent  in  the  coal  as  static 
force,  originally  coming  in  the  form  of  dynamic  force 
-light  and  heat-from  the  sun,  that  great  primal 

source  of  power.  .         

In  the  galvanic  battery  we  see  chemical  force 
converted  into  electricity,  and  in  the  conducting  wire 
we  have  the  transformation  of  electric  force  into  heat. 
In  the  organic  world  we  witness  the  metamorphosis 
of  light,  heat  and  chemisra  into  those  forces  which  are 
called  vital.* 


#  "  It  is  now  an  admitted  doctrine  that  the  nervous  power 
is  Kenerated  from  the  action  of  nutriment  supplied  to  the 
body,  and  is  therefore  of  the  class  of  forces  having  a  com- 
mon origin  and  capable  of    being  mutually  converted,  m- 
Cuding  mechanical  momentum,  heat,  electricity^  magnet.sm 
and  chemical  decortiposition.     *     *     *„      .  ^'^f   '"  J*"!; 
vitality   is  not  a  peculiar  force,  but  a  collection  of  the   orces 
oftorganic  matter  in  such  a  way  as  to  keep  up  a  hvmg 
!,r„rture     *    *    *    *    The  nerve  force  that  is  drawn  from 
tie  waste  of  a  given  amount  of  food  is  capable  of   being 
transm  «ed  into  any  other  form  of  animal  life.     Poured  into 
he  muscles  during  violent  conscious  effort,  it  increases  their 
acivT;  passing  to  the  alimentary  canal,  it  aids  in  the  force 
o  dStion;  at  other  points,  it  is  converted  into  sensible  heat; 
whi  fthe  s^me  power  is  found  capable  of  yielding  true  elec 
Trical  currents.    The  evidence  that  establishes  the  common 
b"si    orichanical  and  chemical  force,  heat  and  electricity, 
namely    their  mutual  convertibility    and  common  origin 
LtTbHs'hes  the  nerve  force  as  a  member  of  the  same  group. 
—fRain-  Senses  and  Intellect,  p.  65. 

xLe  Hfe  of  the  highest  as  well  as  the  lowest  organisms 
is  characterized  by  the   manifestation   of  certain  activities 


MAwuc^-iha^^tf^. , 


IS  static 
lie  force 
,  primal 

;al  force 
ing  wire 
ito  heat, 
lorphosis 
rhich  are 


ous  power 
lied  to  the 
ig  a  com- 
iverted,  in- 
lagnetistn, 
It  is  called 
:  the  forces 
ip  a  living 
rawn  from 
e  of   being 
'cured  into 
reases  their 
in  the  force 
nsible  heat; 
g  true  elec- 
[le  common 
electricity, 
non  origin, 
me  group." 

L  organisms 
in  activities 


.  —  5  — 
It  is  a  truism  to  say  that  all  organs  that 
are  e^xercised  must  have  rest.  After  every  con- 
siderable effort  of  the  muscular  system,  a  greater 
or  less  incapacity  for  further  exertion  results,  and 
the  subjective  expression  of  this  incapacity  we 
call  fatigue.  The  tired  muscles  obtain  a  meas- 
ure of  repair  during  the  intervals  of  work,  and 
such  intervals  may  be  frequent  during  the  working 
hours.  We  often  rest  one  set  of  muscles  when  we  are 
working  another  set.     Even  those  actions  which  are 

derivable  from  the  cosmic  environment;  the  energy  which 
we  expend  as  nerve-force,  muscular  contraction,  thought  and 
will  is  but  the  expression  of  destructive  changes  taking  place 
within  our  bodies.  How  much  of  nerve  and  muscular  activity 
is  the  direct  product  of  the  breaking  up  of  ternary  compounds 
in  the  organism— fats,  carbo-hydrates  and  glycogen,  which  are 
stored  up  as  "  reserves"  in  the  tissues— how  much  is  due  to 
direct  tissue  metabolism,  it  is  impossible  to  say;  it  is  certain, 
however,  that  parts  of  the  body  that  undergo  exercise  waste 
pari  passu  with  that  exercise,  and  that  in  undergoing  disinte- 
gration, the  static  force  that  gave  them  structural  form  and 
function  is  set  free  as  dynamical  energy,  and  in  accordance 
with  the  substratum  throughout  which  it  is  liberated,  mani- 
fests itself  as  some  form  of  vital  force. 

Plants  expend  little  motion,  and  consequently  their  waste 
is  inappreciable.  Actiniae  kept  in  an  aquarium  diminish 
little  in  bulk  from  prolonged  abstinence.  Even  fish,  which 
are  much  more  active  than  other  aquatic  creatures,  suffer 
little  loss  of  substance  when  kept  long  unfed.  The  same  ■ 
remark  applies  with  greater  pertinency  to  cold-blooded  animals 
and  to  hibernating  animals.  On  the  contrary,  warm-blooded 
animals  in  a  state  of  normal  activity  expend  much  energy  and 


- 


•flM 


_  6  — 

most  continuous,  as  respiration  and  the  pulsations  of 
the  heart,  have  distinct  periods  of  suspension.     Jt  is  a 
mistake  to  suppose  that  the  heart  and  lungs  never 
rest.     After  each  contraction  and  dilatation  of  the 
heart,  as  Hammond  reminds  us,  there  is  a  pause  of 
one-fourth  the  time  of  a  beat  in  which  the  heart  rests 
and  is  repaired.    Hence  the  heart  may  be  said  to  rest 
six  hours  out  of  the  twenty-four.     After  each  respira- 
torv  act,  there  is  a  pause  equal  to  one-third  of  the 
whole  time;  thus  the  lungs  rest  eight  hours  out  of  the 
twenty-four.     But  for  the  busy  brain,  there  are  no 
sufficient  seasons  for  rest  during  the  working  hours. 
The  latest,  most  elaborate,  most  noble  product  of 
evolution,    superadded   to  the    spinal    and   sensory 
ganglia  of  the  animal  economy  ages  after  the  auto- 
matic action  of  these  centres  had  been  established  by 


waste  much  substance.f  This  waste  must  be  made  good  by 
repair.and  the  conditions  of  repair  are  a  normal  supply  of  food 
a  normal  circulation,  and  opportunity  for  appropriation  of 
pabulum.  If  this  opportunity  be  not  afforded  from  moment  to 
moment;  if  synchronous  with  waste,  repair  cannot  go  on, 
suitable  seasons  must  ensue  when  the  equilibrium  may  be  re- 
stored. If  the  system  cannot  in  its  entirety  be  refected  while 
work  is  going  on,  work  must  stop  while  the  system  is  being 
refected.  The  machine  is  out  of  repair,  and  business  must 
be  suspended  while  it  is  having  an  overhauling.  These 
considerations  give  hints  as  to  the  true  meaning  of  sleep. 

tVide  Herbert  Spencer's  ?"«=>?>" ''^«|°'°«y' '^^V'' ^The  onW 
which  I  have  borrowed  several  illustrations  of  the  law  stated.  The  only 
ratlsfacto^  explanation  of  the  phenomenon  of  sleep  is  furn.shed  by  such 
biological  inductions. 


-mfttrntidmii^Kf 


ions  of 

Jt  is  a 
i  never 

of  the 
ause  of 
irt  rests 
i  to  rest 
respira- 

of  the 
t  of  the 

are  no 
r  hours, 
duct  of 

sensory 
le  auto- 
ished  by 

;  good  by 
ijr  of  food, 
riation  of 
noment  to 
lOt  go  on, 
may  be  re- 
eled while 
1  is  being 
ness  must 
{.  These 
'  sleep. 

,  p.  170,  from 
I.  The  only 
hed  by  such 


organization,  and  superadded  for  the  greater  elabora- 
tion of  faculty  and  for  the  more  complete  co-ordina- 
tion of  faculty  with  the  conditions  of  existence,  the 
cerebrum  is  still  the  latest  development  in  the  evolu- 
tion of  the  individual,  and  perhaps  the  most  hetero- 
geneous and  unstable  in  its  molecular  constitution. 

I  do  not  propose  to  go  into  any  lengthy  con- 
sideration of  the  functions  of  the  brain.  I 
assume  the  cerebrum  to  be  the  seat  of  sensa- 
tion, thought,  volition.  The  psycho-motor  centres 
are  located  in  the  post-frontal  and  parietal  regions. 
No  such  precise  localization  for  the  purely  psychical 
centres  is  yet  possible.  "The  endless  variety 
in  the  character  and  complexity  of  our  cerebral 
activities,"  says  Macfarlane,  "implies  the  exist- 
ence of  a  like  multiplicity  of  centres."  Localization 
we  do  indeed  know  in  part.  Ferrier's  teachings  with 
regard  to  the  motor  centres  for  the  muscular  group- 
ings of  the  face,  upper  and  lower  extremities,  etc. 
(which  are  mostly  located  along  the  fissure  of 
Rolando),  are  generally  accepted.  The  visual  centre 
is  in  the  occipito-angular  region;  the  auditory  is  in  the 
temporo-sphenoidal  convolutions.  The  seat  of  smell 
is  probably  in  the  tip  of  the  temporo-sphenoidal  lobe, 
that  of  taste  is  in  the  region  of  the  subiculum  cornu 
ammonis. 

The  seat  of  cutaneous  sensation— tactile,  thermic, 
pathic— located  by  Ferrier  in  the  gyrus  hippocampi 
and  gyrus  fornicatus,  seems  the  rather,  in  accordance 


-  '   ,     ,     _  8  — 

with  a  multitude  of  facts  collected  by  Dana,*  to  be  in 
the  motor  areas  of  the  cortex.  A  study  of  cases 
shows  that  the  the  sensory  centres  for  special  parts  of 
the  body,  /.  e.,  face,  arm,  or  leg,  are  in  general  iden- 
tical with  the  motor  centres  for  those  parts,  but  are 
larger  and  more  diffuse.  The  tactile  sensation  seems 
to  be  more  strictly  confined  to  the  motor  areas. f 

The  centres  of  the  psychical  operations  are 
known  to  be  somewhere  in  the  cortex,  but  apart  from 
the  general  vague  division  of  mind  into  feeling,  intel- 
lect, and  volition,  and  the  recognition  of  the  fact  that 
these  three  aspects  of  mind  are  so  dependent  among 
themselves,  although  characteristic  in  their  manifesta- 
tions that  no  one  could  exist  alone,  no  further  division 
of  mind  is  possible  in  the  present  state  of  science. 

There  is,  however,  a  sort  of  psychical  differentia- 
tion with  definite  localization  of-  which  we  are  war- 
ranted in  speaking,  and  as  the  subject  is  of  import- 
ance in  connection  with  the  physiology  of  sleep,  I 
may  be  pardoned  such  digression  as  may  be  neces- 
sary to  set  forth  views  which  may  now  be  considered 
as  data  of  science. 

Ribot,  in  his  "Diseases  of  Memory,"  remarks 
that  in  physiology  the  distinction  of  partial  memories 
is  now  currently  received.  "  Memory  resolves"  itself 
into  memories,  just  as  the  life  of  an  organism  resolves 


*"  The  Cortical  Localization  of  the  Cutaneous  Sensa- 
tions," Journal  of  Mental  Diseases,  Oct.,  1888.         , 
f  Dana,  loc  cit. 


V  \1\    iTllfliffi-'--'— • 


be  in 

cases 

irts  of 

iden- 

iit  are 

seems 

IS  are 

t  from 

,  intel- 

t  that 

imong 

ifesta- 

ivision 

:e. 

rentia- 

e  war- 

mport- 

eep,  I 

neces- 

lidered 

;marks 
mories 
i*  itself 
;solves 

Sensa- 


—  9  — 

itself  into  the  life  of  the  organs,  tissues,  and  anatom- 
'cal  elements  that  compose  it." 

.  As  memory  is  only  the  sum  of  partial  mem- 
ones,  and  all  our  knowledge  (based  on  memory)  is 
primarily  derived  through  the  senses,  and  as  all  the 
sense-organs  have  their  centres  in  the  cerebrum  where 
the  residua  of  sensations  (to  use  Maudsley's  expres- 
sion) constitute  the  memories  of  each  special  sense 
so  certain  diseased  conditions  may  obliterate  one  set 
of  sense-memories  by  destroying  their  anatomical 
substrata,  leaving,  it  may  be,  intact  the  memories  of 
other  senses. 

Charcot,  in  a  recent  lecture,  has  given  us  a  good 
instance  of    this  suppression   of  certain  groups  of 
memories.     It  was  a  case  of  loss  of  the  mental  vision 
of  objects— forms  and  colors— coming  on  suddenly  in 
a  subject  noted   for  great  intellectual  activity,   but 
especially  for  the  strength   of  his   visual   memory. 
This- individual  would  recall  the  principal  features  of 
a  landscape,  a  painting,  a  play,  with  extraordinary  ex- 
actness and  vividness;  his  imagination  was  keen,  and 
he  excelled  in  perspective.     He  could  readily  recall 
what   he   had   read   by  the  mental  images  of  words 
imes,   sentences,   etc.,   presenting  themselves.      His 
memory  of  persons  and  places  was  wonderful.    After 
the  accident  to  which  allusion  has  been   made,   and 
which  seems  to  have  been  of  the  nature  of  a  limited 
embolism,  he  iost  his  visual  memory  of  forms  and 
colors,  and   was  obliged  in  the  management  of  his 
commercial  affairs  to  have  recourse  to  other  forms  of 
memory  (the  auditive,  tactual,  etc.),  which  were  un- 

in^Tl:-  ^^^  ?^y  ^''"^  ^«  "^«'l'  his  very  home, 
and  the  faces  and  forms  of  the  members  of  his  family 
were  at  first  strange  to  him;  he  recognized  nobody 
•except  by  the  voice;  he  could  only  find  his  place  of 


IfW 


lO   — 


§'■•  i 


business  by  inquiry.  Little  by  httle  us  visual  mem- 
ories  returned,  but  never  completely.  He  had  lost 
the  faculty  of  drawing;  could  no  longer  sketch  the 
form  of  any  object  which  he  had  once  seen.  His 
memory  of  colors  was  gone;  he  could  not  form  the 
mental  image  of  black,  white,  red,  etc.,  and  when  any- 
thine  of  a  bright  hue  was  presented  to  him  he  could 
not  recognize  the  color.  The  larger  part  of  what  he 
had  learned  by  reading  was  forfo"en,  whi^  the 
memory  of  what  had  been  acquired  by  the  auditory 
sense  was  as  vivid  as  ever. 

This  gentleman  wrote  to  Charcot  that  his  in- 
terior vision,"  once  so  active  and  perfect,  "had  com- 
pletely disappeared."     He  could  no  longer  represent 

to  himself  the  forms  and  feat"'-«t.°^h'«.,T:'^^jri 
children,  or  any  other  person  or  object  with  which 
he  had  been  familiar.     His  dreams  were  completely 
changed;  he  now  no  longer  dreamed  of  persons  and 
places,  but  of  voices  and  words.     A  remarkable  con- 
sequence of  the  loss  of  this  mental   faculty  was  the 
change  of  character  which  he  had  experienced.     He 
found  himself  much  less  prone  to  sorrow,  sympathy 
and  moral  emotion  than  formerly     Having  rccen  ly 
lost  a  valued  relative,  he  felt  much  less  poignant  grief 
than  we  would  have  felt  could  he  have  represented  to 
himself  by  the  interior  vision  the  physiognomy  of  thi^ 
relative,  the  phases  of  the  disease  through  which  he 
had  passed,  and  especially,  if  he  could  have  pictured 
to  himself  the  external  effect  produced  by  this  death 
on  the  members  of  his  family.     He  concludes  his  let- 
ter  by  the  remark  that  he  is  now  obliged  to  say  ta 
himself  the  things  which  he  wishes  to  retain  in  his 
memory,  whereas,  before  the  occurrence  of  his  cere- 
bral lesion,  he  had  only  io  photograph  them  by  sight  in 
order  to  remember  them. 


HiMi« 


mem- 
id  lost 
:h  the 
His 
m  the 
n  any- 
I  could 
hat  he 
le  the 
iiditory 

is  "in- 
d  corn- 
present 
ife  and 
which 
ipleteljr 
ns  and 
)le  con- 
iras  the 
d.     He 
mpathy 
recently 
int  grief 
;nted  to 
iT  of  this 
rhich  he 
pictured 
is  death 
5  his  let- 
say  to 
in  in  his 
lis  cere- 
sight  in 


—  II  — 

Charcot  concludes  some  very  judicious  and  in- 
structive comments  on  this  interesting  case,  of  whose 
details  we  have  given  but  an  imperfect  idea,  by  the 
followmg  observations:     "  It  cannot  now  be  denied 
that  the  possible  and  actual  suppression,  in  numerous 
instances,  of  an  entire  group  of  memories,  of  a  whole 
category  of  commemorative  images,  without  the  par- 
ticipatioh  of  other  groups,  of  other  categories,  is  a 
capital  fact  in  pathology  as  well  as  in  cerebral  physi- 
ology;  It  leads  necessarily  to  the  admission  that  these 
divers  groups  of  memories  have  their  seat  in  certain 
determined  regions  of  the  encephalon,  and  adds  an- 
other proof  to  those  already  existing  that  the  hemi- 
spheres of  the  cerebrum  consist  of  a  certain  number  of 
ditferentiated  organs,  of  which  each  possesses  its  proper 
function,  while  remaining  in  the  most  intimate  con- 
nection   with   the  others.      This  last   proposition  is 
moreover,  to-day   generally  admitted  by  those  who 
study  the  functions  of  the  brain,  not  only  in  animals, 
in  the  laboratory,  but  also,  and  especially,  in  man,  by 
the  procedures  of  the  anatomo-clinical  method." 

To  sum  up,  then,  the  cerebrum  is  the  great 
centre  of  sensation,  perception,  and  ideation,  of  con- 
scious, emotional,  voluntary  activity.  Pulses  of  mole- 
cular  motion  from  the  brain  are  being  continually 
diffused  throughout  the  body,  and  the  healthy  per- 
formance of  its  office  by  every  part  of  the  body  de- 
pends largely  on  these  gushes  of  nervous  energy. 
There  are  differences  in  molecular  activity  between 
nerve  fibres  and  nerve  cells.  "  While  the  matter  com- 
posing a  cell  is  built  up  of  enormously  complex  ag- 
gregates of  molecules,  wholly  unshielded  from  ex- 


—     12    

ternal  disturbance,  the  nerve  matter  of  a  fibre  is  pro- 
tected throughout  its  entire  length  by  a  membranous 
sheath.     And  while  it  is  probable  that  the  action  go- 
ing on  in  a  cell  consists  in  the  continual  fall  of  un- 
stably arranged  molecules  into  a  state  of  more  stable 
equilibrium,  from  which  a  fresh  rush  of  blood  is  con- 
tinually   raising  them  to   their  unstable  state,   it  is 
probable  that  the  action  going  on  m  a  fibre  consists  m 
the  successive  isomeric  transformation  and  retrans- 
formation  of  the  system  of  molecules  which  make  up 
the  fibre  "      "  The  cell  is  the  place  where  nervous 
energy  is  liberated,  while  the  fibre  _is  a  path  along 
which  nervous  energy  is  transmitted."* 

The  amount  of  molecular  energy  locked  up  in  a 
nerve  centre  is  proportionate  to  the  amount  of  unsta- 
ble nerve  matter  awaiting  decomposition;   and  the 

»  This  view  is  well  brouglit  out  by  Virchow.      He  be- 
lieves  that  all  function  (or  activity  of  all  kinds  in  tissues    is 
due  to  changes  of  place  in  the  minute  particles  o    the  cell 
contents.     This  change  of  place  is  almost  '"^t^Tn^r  n 
transmitted  through  all  the  cells  in  proximity.     ^  change    n 
the  electrical  state  of  the  part  is  connected  with  it.      Vir- 
chow's  view  that  restitution  of  function  does  not  always  de- 
pend on  a  fresh  absorption  of  nutritive   material  may  per- 
Lps  seem  novel.     Rest  alone,  he  says,  is  often  sufficient  t_o 
enable  the  cells  in  a  very  short  space  of  time  to  renew  the  r 
activity      The  molecules  which  had  quitted  their  usual  posi- 
Z  gradually  revert  to  it.  and  hence  are  ready  for  function 
again.     Virchow  seenis  to  have  proved  this  by  e'^P"""*"" 
on  nerves  which  have  been  cut  out  of  the  body.-[Cellular 

Pathology,  p.  327- 


s  prc- 
ranous 
on  go- 
of un- 
:  stable 
IS  con- 
5,   it  is    ' 
isists  in 
etrans- 
ake  up 
'.ervous 
1  along 

up  in  a 
E  unsta- 
ind  tiie 

He  be- 

Issues)  is 
■  the  cell 
taneously 
hange  in 
it.  Vir- 
Iways  de- 
may  per- 
fiicient  to 
new  their 
sual  posi- 
•  function 
periments 
-[Cellular 


—   '3  — 
greater  the  (juantity  of  motion   liberated,  the  less  of 
material  remains  for  the  liberation  of  motion.*    Hence 
the  diminished  readiness  with  which  the  nervous  cen- 
tres respond  to  stimuli  after  a  few  repetitions  of  the 
disturbance.     The  amount  of  explosive   material  is 
lessened  with  each  explosion.     The  enfeeblement  of 
nerve-centres  when  caused  by  moderate  action  is  in- 
conspicuous, for  the  disintegrated   mass  speedily  re- 
integrates  itself  from  the  materials  brought  in  the 
blood.f     But  if  the  stimulation  and  consequent  dis- 
charge are  violent,  or  very  often  repeated,  then  repair 
falls  so  far  in  arrear  of  waste  that  the  nerve  centres 
become  partially  or  completely  incapacitated.    "All  the 
unstable  substance  within  easy  reach  of  the  incoming 
disturbance  has  been  decomposed,  leaving  only  such 
part  as  is  most  removed  from  ordinary  disturbances 
and  can  be  affected  only  by  excessive  ones."     As  ex- 
amples we  need  only  to  be  reminded  of  the  tired 
horse  that  needs  persistent  urging  and  the  continued 
and  often  excessive  use  of  the  lash  to  make  him  con- 
tinue his  pace.     Also  of  the  effect  of  friction  of  the 
skin  in  causing  paralysis  of  the  vaso-motor  nerves  and 
cutaneous  congestion.     The  familiar  experiment  of 
the  effect  of  irritating  the  web  of  the  frog's  foot  is  to 
the  point.     The  arteries  are  at  first  contracted  under 
the  stimulus;  "the  strong  impression  conveyed  to  the 
vaso-motor  centres  there  liberates  an  excessive  dis- 

*  Spencer's  Psychology,  vol.  i,  p.  89. 
t  Herbert  Spencer,  loc.  cit.,  p.  89.  . 


""F= 


—  14  — 
Charge  along  the  fibres  supplying  those  arteries,  caus- 
ing  spasmodic  contraction  of  their  muscular  coats. 
The  second  result  is  that  these  arteries  dilate,  losing 
their  normal  contractility;  they  become  distended 
with  blood,  and  the  part  is  congested.  That  this  is 
due  to  extreme  prostration  or  temporary  paralysis  of 
the  vaso-motor  centre  has  been  clearly  proved,  for  if 
the  nerve-trunk  containing  the  vaso-motor  fibres  be 
dissected  out  and  artificially  irritated,  the  dilated  ar- 
teries  instantly  contract."* 

Mr    Herbert  Spencer,  from  whom   I  have  bor- 
rowed these  illustrations  respecting  the  vaso-motor 
nerves,  has  hardly  done  more  than  gather  up  into  a 
complete  whole  the  generalizations  of  his  leading  sci- 
entific contemporaries.     Virchow,  for  example,  in  his 
Cellular  Pathology,  p.  i49,  has  said  substantially  the 
•  same  respecting  the    action    of   vaso-motor   nerves 
under  stimulation,  and  the  readiness  with  which  they 
are  exhausted.     In  the  smaller  vessels,  with  few  mus- 
cular fibres,  the  exhaustion  follows  so  speedily  the 
stimulation  that  it  seems  as  if  the  irritant  had  pro- 
duced  no  contraction,  so  soon  does  relaxation  follow. 
These    familiar    truths  explain   why    the  brain 
needs  the  rest  of  the  night.     Repair  and  waste  are 
not  evenly  balanced  during  the  waking  hours.    Waste 
has  got  in  excess  of  repair.     Not  that  no  repair  has 
been  going  on  during  the  working  hours-nutntion  is 
actively  going  on  at  all  times,  and  in  the  spinal  cord 

*  Loc.  cit.,  p.  87. 


If' 


,,  caus- 

coats. 

losing 
tended 
this  is 
jTsis  of 
I,  for  if 
>res  be 
;cd  ar- 

fe  bor- 
)-motor 
I  into  a 
ing  sci- 
:,  in  his 
ally  the 
nerves 
ch  they 
>w  mus- 
lily  the 
ad  pro- 
i  follow, 
e  brain 
aste  are 
Waste 
ipair  has 
trition  is 
nal  cord 


—   '5     - 
and  medulla  oblongata  it  is  probablp  tl.at  repair  ever 
keeps  pace  with  waste,  or  falls  but  l.ttic  in  arrear, 
equilibrium  being  quickly  restored.      The  peniliar 
functions  of  these  lower  centres  are  of  an  automatic 
kind,  stimuli  always  producing  responsive  discharges 
along  established  lines.     It  would  certainly  be  for  the 
advantage  of  every  species  in  the  struggle  for  e.xist- 
tence  that  those  automatic  functions  should  be  per- 
formed at  such  an  even,  uniform  rate  that  repair  and 
waste  should  be  in  equilibrium.      Such  is  the  condi- 
tion of  these  nerve  centres.     From  minute  to  minute 
brief  pauses  occur,  when  waste  is  made  good  by  re- 
pair.  This  was  shown  to  be  true  in  respect  to  respira- 
tion,  the  pause  after  each  respiratory  act  giving  the 
bulb  sufficient  time  for  repose  and  repair. 

With  the  cerebrum  the  case  is  somewhat  different. 
"  Its  substance  is  consumed  by  every  thought  by 
every  action  of  the  will,  by  every  sound  that  is  heard, 
by  every  object  that  is  seen,  by  every  substance  that 
IS  touched,  by  every  odor  that  is  smelled,  by  every 
painful  or  pleasurable  sensation,  and  so  on.  Each 
mstant  of  our  lives  witnesses  the  decay  of  some  por- 
tion of  Its  mass,  and  the  formation  of  new  material 
to  take  its  place."* 

Hence  the  need  of  that  periodical  repose  we  call 
sleep.  Sleep  becomes  emphatically  "tired  Nature's 
sweet  restorer,"  "balm  of  hurt  minds,"  "chief  nour- 

*  Hammond.  "  Sleep  and  its  Derangements."  p.  12. 


r 


,_-,«B^****«  ■"*" 


•  _  16  — 

isher  in  life's  feast."     In  this  adaptation  of  organisms 
to  the  waste  of  the  day  and  the  repair  of  the  night 
Herbert  Spencer  sees  an  example  of  the  prmc.ple  of 
survival  of  the  fittest.     "An   animal  so  constituted 
that  waste  and  repair  were  balanced  from  moment  ta 
moment  throughout  the  twenty-four  hours,  would 
other  things  being  equal,  be  overcome  by  an  enemy 
or  competitor  that  would  evolve  greater  energy  dur- 
ing the  hours  when  light  facilitates  action,  at  the  ex- 
pense of  being  less  energetic  during  the  hours  of 
darkness  and  concealment.     Hence  there  has  neces- 
sarily  established  itself  that  rhythmical  variation  ,n 
nervous  activity  which  we  see  in  sleep  and  waking. 
(Principles  of  Psychology,  vol.  1,  p.  88). 

Antecedents  of  5/../.-There  is  every  reason  to 
believe  that  one  of  the  antecedents  of  sleep  is  a  cer- 
tain change  in  the  composition  of  the  ^ood  circula  - 
ing  in  the  capillariesof  the  pia  mater,where  by  the  nutri- 
tion of  the  cortical  cells  is  diminished.     This  change 
may  be  regarded  as  an  accumulation  of  waste  extrac- 
tives    There  is  also    doubtless  another  factor,  as 
staged  by  Pflugger;  the  brain  is  extremely  sensitive 
to  the  want  of  oxygen,  e.g.,  when  frogs  are  deprived 
of  this  element  for  any  length  of  time,  they  fall  into 
a  condition  resembling  sleep.     Some  experiments  of 
Pettenkofer  and  Voit  make  it  apparent  that  oxygen 
accumulates  in  the  blood  during  sleep  to  be  utilized 
during  the  waking  hours;  deficiency  or  absence  of 
this  "change-compelling"  element  may  well  cause 


janisms 
!  night, 
ciple  of 
istituted 
ment  to 
would, 
I  enemy 
rgy  dur- 
;  the  ex- 
hours  of 
IS  neces- 
iation  in 
waking."^ 

•eason  to 
( is  a  cer- 
circulat- 
the  nutri- 
is  change 
te  extrac- 
[actor,  as 
sensitive 
deprived 
J  fall  into 
•iments  of 
at  oxygen 
)e  utilized 
absence  of 
well  cause 


_  17  _ 

that   lethargy  of  function   whose  full  expression  is 
sleep.* 

Another  antecedent  of  sleep  is  lethargy  of  the 
circulation.  There  are  probably  several  factors  in 
this  change.  Less  blood  is  attracted  to  the  cortex 
by  the  cells  becoming  functionally  inactive,  and  the 
tired  brain  sends  diminished  energy  to  the  heart,  and 
there  is  a  slowing  of  the  circulation.  With  a  diminu- 
tion of  vaso-dilator  influence  in  the  higher  ganglia 
there  may  be  an  augmentation  of  vaso-dilator  in- 
fluence in  automatic  ganglia  lower  down  (the  inhib  i- 
tory  agency  of  the  hemispheres  being  withdrawn), 
hence  a  narrowing  of  the  calibre  of  the  cerebral 
arterioles  and  a  lessened  blood  supply.  During 
sleep,  then,  it  is  believed  that  the  proper  functions 
of  the  cerebrum  are  mostly  suspended,  nutrition 
only  being  active;  the  constricted  arterioles  supply- 
ing just  enough  blood  to  the  nerve  cells  that  the 
requisite  reparative  processes  may  be  performed. 

*  These  experirr.enters,  by  an  ingenious  laboratory  con- 
trivance,  were  enabled  .  .  measure  the  amount  of  oxygen 
inhaled  and  of  carbonic  acid  exhaled  during  the  24  hours. 
A  healthy  man  was  put  into  the  test  chambers  with  the  light 
occupation  of  taking  to  pieces  the  works  of  a  watch.  Of  the 
total  quantity  of  oxygen  inhaled  by  him,  33  per  cent,  was 
absorbed  during  the  day,  ?nd  about  double.  67  per  cent 
during  the  night.  This  goes  far  to  prove  that  night  is  the 
time  for  storing  up  oxygen  to  be  used  during  the  day  in  the 
production  of  work.— [North  British  Review,  June,  1868  p. 
269.  ' 


~=^-'-^-^*--^r\\'\- Ti  uriiinmitilr^iTwrii 


fp" 


i 


II 


—  i8  — 
This  relatively  anaemic  condition  of  the  cerebrum 
during  sleep  has  been  proved  by  numerous  well  at- 
tested observations,  as  those  of  Sir  Astley  Cooper, 
Pierquin,  Donders,  Durham,  Hammond,  Mosso,  and 
others.    The  experiments  of  Hammond  were  made 
on  dogs  from  whose  crania  portions  of  bone  were 
trephined,   exposing  the  brain  and   its  membranes. 
The  details  of  these  experiments  are  now  sufficiently 
known  since  their  publication  in  his  book  on  "  Sleep 
and    its    Derangements."      Durham's   observations, 
which  were  several  years  prior  to  Hammond's,  also 
pertained  to  dogs. 

Pierquin's  case  is  recorded  by  Dendy  in  his  "  Philo- 
sophy of  Mystery."  and  elsewhere.*  A  girl  in  Montpellier 
had  lost  a  large  portion  of  her  scalp  and  skull.  The  brain 
could  be  seen  for  a  considerable  extent  of  surface.  When 
she  was  in  dreamless  sleep,  her  brain  was  motionless  and 
low  within  the  cranium;  but  when  her  sleep  was  imperfect 
and  she  was  agitated  with  dreams  the  cerebrum  moved  and 
beat;  more  blood  coursed  through  the  vessels  of  the  pia 
mater,  and  the  brain  protruded  through  the  holes  in  the 
skull.  •  *  •  When  she  was  awake  and  in  vigorous 
thought,  the  brain  swelled,  and  protrusion  was  very  observ- 
able. 

Professor  Mosso,  of  Turin,  had  the  rare  oppor- 
■    tunity  of  making  similar  observations  on  three  per- 
sons, each  of  whom  had  lost  a  portion  of  the  skull. 
His  studies  of  the  cerebral  circulation  during  sleep 


*  Combe's  Physiology,  p.  143-     Jarvis'  Physiology,  p. 
432.    American  Annals  of  Phrenology,  No.  i,  p.^37- 


Jlfii'-nri^T*-^ 


rebrum 
ell  at- 
^ooper, 
lO,  and 
:  made 
e  were 
branes. 
iciently 
"  Sleep 
irations, 
I's,  also 

"  Philo- 
ntpellier 
he  brain 
When 
iless  and 
mperfect 
>ved  and 
the  pia 
s  in  the 
vigorous 
y  observ- 

;  oppor- 
ree  per- 
le  skull, 
ig  sleep 

iology,  p. 

7- 


-jil  '■«»« 


—    19    _ 

and  during  the  waking  moments  have  been  the  most 
thorough,  and  go  to  show;     "  i.     That  in  the  act  of 
gomg  to  sleep  a  dilatation  and  relaxation  of  the  ves- 
sels of  the  forearm  occur,  with  a  corresponding  con- 
traction  in  the  vessels  of  the  brain,  this  change  be- 
commg  most  pronounced  during  deep  sleep.    2.  That 
all  external  stimulation,  however  slight,  such  as  a  ray 
of  light  falling  upon  the  eye,  a  noise,  etc.,  is  attended 
by  contraction  of  the  vessels  of  the  forearm,  greater 
blood  pressure,  and  an  increased  flow  of  blood  to  the 
brain.    3.     That  these  changes  are  accompanied  by  a 
modification  of  the  respiratory  rhythm,  and  an  ac- 
celeration of  the  pulsations  of  the  heart.    4.     That 
during  sleep,  the  quantity  of  blood  in  the  brain  is  sub- 
ject to  fluctuation  without  any  apparent  cause      5 
That  all  mental  activity  is  attended  by  an  increased 
quantity  of  blood  in  the  brain."  ♦ 

These  facts  seem  to  teach  that  the  sleep  state  is 
attended  with  relative  anaemia  of  the  brain,  and  that 
the  amount  of  blood  supply  to  that  organ  is  in  ratio 
with  the  mental  activity. 

Hammond  regards  this  diminution  of  the  quantity 
of  blood  circulating  in  the  brain  as  the  immediate 
cause  of  sleep,  and  aflirms  that  whatever  cause  is 

*  "  Insomnia  and  its  Therapeutics,"  Macfarlane.  p.  16 
Mosso  devised  special  instruments  by  which  he  took  tracings 
of  the  movements  of  the  brain,  the  pulsations  of  the  heart 
etc.;  he  also  invented  the  Plethysmograph.  for  estimating 
the  quantity  of  blood  in  the  forearm  and  hand. 


20    — 

capable  of  lessening  the  quantity  of   blood   in   the 
brain  is  also  capable  of  inducing  sleep. 

To  this  view  has  been  opposed  the  fact  that  pa- 
tients suffering  from  general  ----  (;[«";^';X; 
rhace  chlorosis,  cachexia,  etc.),  are  often  the  victims 
fTs^mnia,  ani  that  conditions  of  Plethora  are  ot 
attended  with  troublesome  somnolence.     Ligature  of 
the  carotids  in  animals  does  not  produce  a  state  re- 
semS  true  sleep,  and  faradization  of  the  cephahc 
ends  o?  the  two  divided  cervical  sympathetic  cords  m 
animals    while  it  produces  considerable  cerebral  an- 
^mTa    dols  not  Sring  about  the  least  tendency  to 

'°%te"sro*bjectionsappeartometo  be  well  taken, 
and  it  seems  probable  that  the  vascular  and  cardiac 
Lod    cations'are,  as  Vulpian  says,  '' only  accessory 
and  adjuvant,"  "  concomitant  or  consecutive,  play- 
ing no  essential  role  in  the  Phy^'^^^^y  f  ^tfi.  ^^^ht 
At  the  same  time,  there  is  no  doubt  that     slight 
and  gradual  anemia  of  the  brain  is  conducive  to 
s^eep  •'  and  therefore  we  see  the  utility,  m  some  cases 
of  insomnia,  of  hot  pediluvia,  cold,  wet  cloths  to  the 

""""^'m  Sense  of  ira/^«..-Subjectively,  sleep  is  pre- 
ceded by  a  sense  of  fatigue,  which  is  the  more  pro- 
Tounced'the  greater  the  labor  which  ^^as  Produced^^ 
Fatigue  may  be  regarded  as  an  expression  of  waste 

i^i^T^ese  objections  forcibly  stated  by  Vulpian  in  his 

Lemons  sur  VAppareU  VascMoteur,  t.  ).  p.  150. 


pf^  " 


in   the 

at  pa- 
laemor- 
victims 
e  often 
ture  of 
ate  re- 
ephalic 
;ords  in 
ral  an- 
;ncy  to 

1  taken, 

cardiac 

:cessory 

e,  play- 

p." 
"  slight 

ucive  to 

tne  cases 

,s  to  the 

ip  is  pre- 
aore  pro- 
iduced  it. 
of  waste 

)ian  in  his 


21     — 

unbalanced  by  repair;  according  to  Preyer,  lactic  acid 
and  creatine  accumulating  in  the  blood  cause  this 
sensation  by  their  paralyzing  action  on  the  cells  of 
the  cortex. 

"Fatigue,"  says  Benedikt,*  "is  a  property  inher- 
ent in  all  the  nervous  and  muscular  tissues;  but  the 
almost  unlimited  duration  of  certain  automatic  move- 
ments of  pathological  nature  proves  that  the  fatigue 
which  supervenes  after  voluntary  movements  has  its 
origin  in  the  motor  centers  of  the  cortex.  •  •  •  * 
The  sensation  of  fatigue  is  in  a  certain  sense  a  guar- 
anty of  safety  for  the  muscular  apparatus.  In  certain 
pathological  states;,  often  even  by  the  energy  of  the 
^  will  alone  it  may  he  overcome.  But  there  then  fol- 
'  lows  a  still  greater  realization  of  fatigue,  which  may 
be  the  result  of  complete  exhaustion." 

Normal  fatigue  easily  leads  on  to  a  condition  of 
sluggishness  and  languor  known  as  sleepiness.  The 
eyelids  feel  heavy,  the  muscles  relax,  there  is  an  in- 
stinctive disposition  to  shirk  work,  an  inability  to  fix 
the  attention  on  anything  which  requires  thought,  a 
sensation  of  supineness  and  enervation,  a  considerable 
obtuseness  of  the  senses.  Yawning  is  a  phenomenon 
"  indicative  of  a  wearied  attention. "  "  The  head  nods 
and  droops  upon  the  breast,  and  the  body  assumes 
that  position  which  is  most  conducive  to  ease,  com- 
fort, and  entire  muscular  inactivity." 

Another  subjective  antecedent  of  sleep  is  failure 

*La  M/decint  Moderne,  1891,  p.  67. 


—    22    — 

Of  the  attention.     To  this  end,  absence  of  sensorial 
impressions  is  an  important  condition  of  sleep.    1  here 
are  certain  influences  which  are  predisposmg  causes, 
such   as  darkness  and   silence  and    muscular    rest. 
Habitual  sensations,  as  the  continuance  of  an  accus- 
tomed sound,  are  of  the  same  class.     It  is  ow.ng  to 
the  power  of  habit  that  some  persons  can  sleep  more 
soundly  in  the  neighborhood  of  noisy  mills  and  cata- 
racts, than  elsewhere,  the  attention  of  the  individual 
being  more  attracted  by  the  suspension  of  the  sound 
than  by  its  continuance;   for  as  the  exercise  of  the 
attention  implies  an  awakened  and  concentrated  con- 
sciousness, during  such  exercise  sleep  is,  in  the  nature 
of  the  case,  impossible.    Other  predisposing  causes 
are  gentle  tranquilizing  sounds,  such  as  the  piping  of 
crickets,  the  rustling  of  foliage,   the  hum  of   bees, 
hearing  a  dull  book  read,  etc.,  which  conduce  to  sleep 
by  making  on  the  sensorium  a  series  of  monotonous 
impressions  which  are  neither  interesting  enough  nor 
powerful  enough  to  keep  the  attention  aroused  (Car- 

^^"*Ovid  places  the  cave  of  Somnus  in  the  country 
of  the  Cimmerians,  the  fabled  'and  of  shadows,  of 
silence,  and  of  gloom.  The  river  of  Lethe  flows  there, 
and  invites  to  sleep  by  its  murmur,  and  poppies  luxu- 
riate  before  the  cave  of  the  drowsy  god.  Spencer 
locates  the  palace  of  Somnus  in  a  dull  and  darklmg 
part  of  the  earth.  Archimago  sends  a  little  spirit 
down  to  Morpheus  to  fetch  him  a  dream: 


iii 


'-■III, 


sorial 
rhere 
luses, 

rest, 
iccus- 
ing  to 

more 
1  cata- 
vidual 
sound 
of  the 
d  con- 
nature 
causes 
)ing  of 
bees, 
o  sleep 
)tonous 
gh,  nor 
d  (Car- 
country 
lows,  of 
s  there, 
;s  luxu- 
Spencer 
larkling 
tie  spirit 


—  23  — 

"  He  making  speedy  way  through  spersed  ayre. 

And  through  the  world  of  waters  wide  and  deep, 

To  Morpheus'  house  doth  hastily  repaire  , 

Amid  the  bowels  of  the  earth  full  steepe. 

And  low,  where  dawning  day  doth  never  peepe, 

His  dwelling  is.     There  Tethys  his  wet  bed 

Doth  ever  lave,  and  Cynthia  still  doth  steepe 

In  silver  dew  his  ever  drooping  head, 

While  sad  night  over  him  her  mantle  still  doth  spreade. 

And  more,  to  lull  him  in  his  slumber  soft, 

A  trickling  stream  from  high  rock  tumbling  down, 

And  ever  drizzling  rain  upon  the  loft, 

Mixed  with  the  murmuring  wind,  much  like  the  soune 

Of  swarming  bees  did  cast  him  in  a  swoone. 

No  other  noise,  nor  people's  troublous  cries. 

As  still  are  wont  to  alarm  the  walled  towne. 

Might  then  be  heard,  but  Careless  Quiet  lies 

Wrapped  in  eternal  silence  far  from  enemies." 

Amount  of  Sleep  Necessary. — As  sleep  is  a  con- 
structive process,  it  would  seem  that  the  amount  of 
sleep  taken  should  be  proportionate  to  the  mental 
and  physical  e.xercise  of  the  waking  hours.  The 
reparative  value  of  sleep,  however,  is  more  depend- 
ent on  the  depth  and  intensity  of  the  sleep  than  on 
its  duration.  The  invigoration  which  follows  sound, 
dreamless  sleep  is  remarked  by  every  one;  a  little 
sleep  of  this  kind  is  worth  many  hours  of  disturbed, 
dreamy  sleep.  It  would  seem  that  absolute  quies- 
cence and  suspension  of  function  is  that  condition  of 
the  cortical  cells  most  favorable  for  nutrition  and 
repair.  The  principle  of  making  up  for  lost  sleep  is 
a  correct  one;   persons  habituated   to  six   or   seven 


—    34  — 

hours'  sleep  a  day  may  pass  without  inconvenience  a 
night  or  two  without  sleep,  provided  they  can  make 
up  for  this  loss  by  a  more  prolonged  sleep  afterwards. 
It  is  by  dint  of  the  habit  of  sleeping  profoundly 
when  they  do  sleep,  that  some  persons  sleep  but  few 
hours  out  of  the  twenty-four,  and  yet  continue  in 
health.  Frederick  the  Great  and  John  Hunter  are 
said  to  have  required  only  five  hours'  sleep  a  day, 
Pitt  used  to  restrict  himself  to  three  hours.  The 
briefest  sleepers  are  generally  men  of  the  greatest 
mental  activity.  The  best  scholars,  thinkers  and  lite- 
rary men,  according  to  Carpenter,  do  not  spend  more 
than  one-fourth  of  the  diurnal  cycle  in  sleep. 

Persons  of  lymphatic  temperament  are  said  to  be 
the  greatest  sleepers,  from  natural  lethargy  of  the 
nervous  centers. 

Hard,  muscular  toil  promotes  somnolence  more 
than  hard  brain- work;  the  husbandman  and  day 
laborer  sleep  longer  and  more  profoundly  than  the 
student  or  professional  man.  The  waking  state  of 
such  persons  is  characterized  by  great  activity;  the 
wear  and  tear  of  the  muscular  system  is  iipmense, 
and  long  seasons  of  rest  are  needed,  during  which 
the  physical  and  vital  energies  shall  be  largely  occu- 
pied with  the  work  of  muscular  reparation.  Blood 
goes  from  the  brain  to  the  muscle,  and  there  is  rela- 
tive anaemia  of  the  cortex,  a  condition  favorable  to 
the  inertia  of  sleep.  Moreover,  the  cerebral  activity 
of  even  the  humblest  day  laborer  is  not  inconsider- 


snce  a 
make 
wards. 
)undly 
ut  few 
lue  in 
er  are 
a  day; 
The 
reatest 
id  lite- 
1  more 

1  to  be 
of  the 

e  more 
d  day 
an  the 
tate  of 
ty;  the 
imense, 
:  which 
y  occu- 
Blood 
is  rela- 
able  to 
activity 
)nsider- 


—  as  — 

able — the  sensorv,  perceptive,  and  voluntary  faculties 
are  kept  constantly  employed  during  their  daily  occu- 
pations. They  often  toil  for  hours  in  obedience  to  a 
painful  exercise  of  the  will,  amid  an  almost  overpow- 
ering sense  of  muscular  weariness.  Now,  a  purely 
voluntary  act  fatigues  the  brain  more  than  an  involun- 
tary or  automatic  one.  Hence,  the  protracted  sleep 
of  the  day  laborer  must  be  due  in  a  considerable 
degree  to  cerebral  waste. 

The  relationship  of  muscular  exercise  and  muscu- 
lar fatigue  to  the  intra-cranial  energies  and  circula- 
tion may  not  be  demonstrably  clear,  but  the  fact  is 
none  the  less  certain  that  muscular  exertion  is  one  of 
the  most  powerful  promoters  of  sound  sleep. 

Dreams. — Dreams,  from  a  psychological  point  of 
view,  constitute  the  most  interesting  phenomena  con- 
nected with  sleep;  from  a  medico-physiological  point 
of  view,  they  are  chiefly  of  interest  as  indicating  that 
the  sleep  is  not  sound,  /.  e„  only  partial.  In  dreams, 
the  cerebrum  is  in  part  awake;  the  automatic  (earliest 
evolved,  most  organized)  centres  of  mind  resume  a 
measure  of  their  activity,  while  the  will*  is  still  dor- 


*  I  use  the  term  as  expressive  of  the  sum  of  the  higher 
metital  activities.  These  may  be  regarded  as  the  latest 
evolved,  most  consummate  results  of  evolution — the  last 
developed  in  individual  biological  history  and  the  soonest 
lost.  The  effects  of  physical  tire  earliest  manifest  themselves 
in  modifications  of  the  functional  efficiency  of  the  organic 
substrata  of  these  faculties;  the  truly  automatic  substrata 
are  more  stable  and  capable  of  more  prolonged,  unresting 


I 


■ : 


—    26    — 

mant.  A  limited  area  of  brain  is  brought  into  a  con- 
dition of  waking  excitement;  certain  ideas  and  emo- 
tions result,  which,  not  being  modified  by  comparison, 
and  reflection  by  other  ideas  and  feelings  which  are 
asleep,  present  a  phantasmagorical  succession  of 
images  to  the  consciousness. 

Hammond  suggests  that  the  cause  of  that  sus- 
pension of  the  judgment  which  characterizes  sleep 
resides  in  some  alteration  in  the  circulation  of  the 
blood  in  that  part  of  the  brain  which  presides  over 
the  judgment,  whereby  its  power  is  suspended  and  the 
imagination  left  free  to  fill  the  mind  with  its  incon- 
gruous and  fantastic  images. 

And  yet,  judgment,  like  volition,  is  a  very  com- 
plex phenomenon.  It  implies  the  possession  of  one's 
principal  mental  acquisitions,  one's  stores  of  experi- 
ences; it  implies  comparison,  choice.  The  experi- 
ences themselves  may  not  be  actually  present  to  the 
consciousness,  but  certain  residua — unconscious  gen- 
eralizations—from these  experiences,  most  be  there 
that  judgment  may  be  exercised  on  the  c-isc  at  issue. 
It  is  plain  that  the  imperfect  sleep  consciousi'-js  i» 
inadequate  to  such  exercise  of  comparison. 

We  have  not  time  to  linger  on  this  interesting 
topic  covering  which  volumes  have  been  written.  It 
is  perhaps  better  to  leave  this  domain  to  the  poet  and 


activity,  as  is  shown  by  abundance  of  pathological  facts. 
(See  Hughlings  Jackson's  Lectures  on  Evolution  and  Dissolu. 
tion  in  the  Nervous  Centres.) 


con- 
emo- 
rison, 
h  are 
n    of 

t  sus- 
sleep 
if  the 
over 
id  the 
ncon- 

com- 
one's 
xperi- 
speri- 
to  the 
gen- 
there 
issue. 
^>s  is 

esting 
n.  It 
it  and 

facts, 
lissolu* 


—  a?     - 

the  metaphy.sician,  to  whom,  as  rightful  property, 
dreams  belong.  We  may  remark,  in  passing,  that 
the  loss  of  association  of  ideas  prevails  as  much  in 
dreams  as  in  the  waking  state. 

"  Lulled  in  the  countless  chambers  of  the  brain 
Our  thuuKhts  are  linked  by  many  a  hidden  ch.iin. 
Awake  but  one,  and  lol  what  myriads  rise. 
Each  stamps  its  image  as  the  other  iiies. 
Each  thrills  the  seat  of  sense,  that  sacred  source 
Whence  the  firm  nerves  direct  their  mazy  course, 
And  through  the  frame  invisibly  convey 
Their  subtle,  quick  vibrations  as  they  play." 

The  dream  images  that  "thrill  the  seat  of  sense" 
are  a  revival  of  registered  sense  impressions  rendered 
peculiarly  vivid  because  the  natural  channels  between 
the  outward  world  and  the  sensorium  are  closed. 
Hence,  not  being  corrected  by  an  incoming  torrent  of 
objective  impressions,  they  engross  the  relatively 
meagre  and  imperfect  sleep-consciousness,  and  seem 
realities.  The  same  brain  tract  which  is  excited  by 
the  objective  sense  impression  is  occupied  by  the 
revived  subjective  image  (Carpenter,  Bain,  Spencer), 
If  we  dream  of  things  seen  or  felt  or  heard,  it  is  the 
centres  of  those  respective  senses  that  are  called  into 
action,  with  such  portions  of  the  hemispherical  (cor- 
tical) ganglia  as  have  organic  connections  with  them. 
It  is  remarked  by  Macfarlane  that  when  many  cen- 
tres are  active,  dreams  are  consistent  and  coherent, 
while  when  few  centres  are  working,  they  are  unreal 


~I 


WHMWIUH*' 


mmn0f 


—  28  - 
and  extravagant,  /.  r,  tlie  difference  in  the  quality  of 
the  dreams  depends  on  the  depth  of  the  sleep.* 

Dreams  are  principally  of  interest  to  the  phy- 
sician as  being  an  indication  of  unsound  sleep.  The 
dreaming  period  .seldom  comes  on  in  health  till  the 
time  for  waking  approaches.  Then  the  centres  that 
are  most  automatic  one  by  one  recover  their  functional 
activity,  those  which  represent  the  higher  mental 
powers  still  remaining  dormant.  It  is  doubtless  true 
that  in  sound  sleep  we  never  dream.  If  anything  has 
been  settled  by  the  labors  of  physiologists  during  the 
past  forty  years,  it  is  I  think  this,  that  the  vascular 
and  other  conditions  of  perfect  sleep  forbid  any  men- 
tal manifestations.  The  condition  of  sound  sleep  is 
one  of  complete  psychical  inertia.  A  transcendental 
philosophy  which  teaches  that  the  mind  is  always 
conscious  and  always  active  must  have  some  higher 
foundation  on  which  to  rest  than  common  sense  and 
experience. 

If  the  dreaming  period  coihes  on  early,  it  Is  evi- 
dence of  some  irritation  in  some  part  of  the  body 
which  is  disturbing  the  rest  of  the  brain.  Thus,  un- 
seasonable dreaming  is  often  symptomatic  of  indiges- 
tion, teething,  a  febrile  condition,  the  influence  of 
some  toxic  agent  (tea,  coffee,  alcohol,  etc.),  and  when 
dreams  become  pathological,  it  is  a  part  of  the  phy- 
sician's duty  to  discover  the  cause  and  remedy  it. 

*  Loc.  cit.,  p.  31. 


ty  of 

phy- 
The 
1  the 
that 
ional 
ental 
I  true 
g  has 
J  the 
cular 
men- 
ep  is 
ental 
I  ways 
igher 
e  and 

s  evi- 
body 
s,  un- 
diges- 
ice  of 
when 
phy- 
t. 


♦     CHAPTER  II. 

INSOMNIA. 

If  the  essential  condition  of  sleep  be  torpor  of 
the  centres  of  conscious  mentality,  everything  which 
excites  these  centres  and  keeps  them  functionally 
active  will  promote  insomnia. 

In  discussing  the  causes  of  insomnia  I  shall  adopt 
in  part  Professor  See's  classification,  and  shall  con- 
sider these  cases  as:    I.   Psychical;  and,  II.  Physical. 

I.  Under  the  head  of  I'sychical  Insomnia  are 
included  cases  of  sleeplessness  due  to  to  mental  emo- 
tion, to  thought,  worry — /.  /•.,  internal  causes  not  di- 
rectly dependent  on  organic  states  or  outward  excita- 
tions. This  kind  of  insomnia  is  that  with  which  the 
author  of  "Night  Thoughts"  was  (presumably) 
affected: 

"  From  short,  us  usual,  and  disturbed  repose, 
I  wake.     How  happy  those  that  wake  no  more! 
I  wake  emerging  from  a  sea  of  dreams 
Tumultuous,  where  my  wrecked  despondent  thought 
From  wave  to  wave  of  fancied  misery 
At  random  drove,  her  helm  of  reason  lost!" 

Insomnia  of  the  psychical  order  is  illustrated  in 
the  student  who  is  anxious  about  his  examinations 
and  cannot  obtain  rest  till  the  result  is  known;  in  the 
candidate  for  political  honors  who  cannot  sleep  till 
the  election  is  over  and  his  fate  is  decided;  in  the 
mother  who  will  watch  over  her  sick  child  night  after 


—  30  — 
night,  not  closing  her  eyes  till  the  crisis  of  the  sick- 
ness is  passed.  Multitudes  of  such  instances  happen 
in  daily  experience.  In  order  that  natural  sleep  may 
occur,  the  mind  must  be  tranquil;  on  this  point  it  is 
useless  to  enlarge. 

The  pure  hypnotics— chloral,  paraldehyd,  ure- 
than,  sulphonal— are  generally  quite  efficacious  in  the 
insomnia  due  to  emotional  causes,  the  intensity  of  the 
insomnia  being  of  course  proportional  to  the  intensity 
of  the  disturbing  cause.  Business  cares  and  anxieties 
of  all  kinds,  and,  I  may  add,  homesickness  and 
disappointments,  often  produce  a  most  obstinate 
wakefulness,  which  hardly  yields  to  even  large  doses 
of  chloral;  sulphonal  is  almost  without  effect.  In 
such  cases  the  therapeutist  is  almost  without  re- 
sources. 

"  Who  shall  minister  to  a  mind  diseased, 
Pluck  from  the  memory  a  rooted  sorrow, 
Rase  out  the  written  troubles  of  the  brain, 
And  with  some  sweet  oblivious  antidote 
Cleanse  the  stuffed  bosom  of  that  perilous  stuff 
Which  weighs  upon  the  heart?" 

Under  the  head  of  psychical  insomnia  may  also 
be  classed  sensorial  disturbances  of  an  unusual,  in- 
tense, or  persistent  nature,  whether  of  sight  or  of  hear- 
ing, which  prevent  sleep.  But  these  causes  are  so 
familiar  to  everybody  that  it  suffices  simply  to  men- 
tion them— illustrations  are  innumerable.  Prof.  St'e 
alludes  to  the  effect  often  produced  by  prolonged 


le  sich- 
happen 
ep  may 
)int  it  is 

yd,  ure- 
is  in  the 
y  of  the 
intensity 
inxieties 
3SS  and 
)bstinate 
je  doses 
ect.  In 
lout   re- 


stuS 

may  also 
usual,  in- 
r  of  hear- 
ts are  so 
y  to  men- 
Prof.  St  e 
jrolonged 


—  31  — 
application  of  the  eyes  to  reading  and  to  the  micro- 
scope, especially  in  the  evening;  this  frequently  pro- 
vokes subjective  excitations— "phosphenes"— whose 
constant  reappearance  prevents  repose.  It  is  useless 
to  say  that  this  kind  of  insomnia,  being  caused  by 
physical  agents,  might  properly  come  under  the  next 
division. 

II.  Under  the  head  of  Physical  Insomnia,  I 
shall,  I,  take  up  the  group  of  physical  causes,  fore- 
most among  which  are  organic  conditions  productive 
of  PAIN.  If  an  irritation  emanating  from  any  organ 
or  tissue  may  keep  consciousness  aroused  and  the 
cortex  active  when  not  painful,  how  much  the  more 
will  it  be  likely  to  produce  insomnia  when  raised  to 
tha!*  degree  of  intensity  known  as  pain  ?  Pain  implies 
a  peculiar  e.xcitation  of  the  sensory  cortical  centres 
and  an  awakened  consciousness,  and  its  very  exist- 
ence is  inimical  to  sleep. 

It  is  not  necessary  to  dwell  long  on  the  causes  of 
pain.  It  maybe  peripheral  or  visceral;  may  be  due 
to  inflammatory  states  of  the  nerve  centres  or  their 
membranes,  or  to  functional  disturbances  of  nerves, 
contituting  neuralgia;  to  conditions  of  anaemia  or 
hyperaemia;  to  inflammation  and  suppuration;  to  ul- 
cerative processes;  to  the  pressure  of  tumors,  exuda- 
tions, etc. 

The  leading  therapeutical  indication  is  to  remove 
the  cause.  This  may  be  easy  of  accomplishment,  as 
■when  the  pain  is  from  a  carious  tooth,  or  an  abscess. 


s 

^ 


^■Jto.ii**  *»»'»« 


.ii^-tf"^ 


_  32  — 

or  it  may  be  impossible  to  meet,  as  in  many  cases  of 
locomotor  ataxia  with  douleurs  fulgurantes,  m  the  pam 
of  internal. cancer,  etc.     The  pain  of  migrame  offers 
this  peculiarity  that  it  generally  yields  to  the  desire 
for  sleep;  other  forms  of   neuralgia  are  apt  to  be 
worse  at  night.    Often  the  causal  indication  must  be 
kept  in  abeyance;  the  first  thing  to  attend  to  is  the 
inciicatio  morbi.   A  hypodermatic  injection  of  morphine 
may  be  imperatively  required,  and  it  may  be  waste  of 
time  to  attempt  to  relieve  the  pain  by  other  remedies. 
In  the  insomnia  due  to  cancer,  to  acute  inflammation 
(pleurisy,  pneumonia,  peritonitis,  pericarditis),  abscess, 
the  lightning  pains  of  ataxia,  to  severe  neuralgic  at- 
tacks, it  will  not  always  be  possible  to  obtain  the 
relief  requisite  for  sleep  without  recourse  to  opium  or 
morphine.     It  is  undeniable,  however,  that  in  anti- 
pyrin,  phenacetin,  acetanilid,  and  other  of  the  new 
analgesics,  we  may  often  find  good  and  comparatively 
harmless  substitutes  for  opium  or  morphine.    Thus 
there  is  a  large  amount  of  testimony  to  the  benefits 
obtained  from  phenacetin,  antipyrin,  etc.,  in  the  pams 
of  acute  rheumatism,  facial  neuralgia,   hemicrania, 
lumbago   and   pleurordynia,  neuritis,  zona,  sciatica, 
and  even  in  the  douleurs  fulgurantes  of  tabes. 

The  analgesic  action  of  belladonna,  cannabis 
Indica,  hyoscyamus,  is  sometimes  sought  in  insomnia 
due  to  pain;  not  much  reliance,  however,  can  be 
placed  on  any  narcotic  but  opium. 

There  will  always  be  one  objection  agamst  opium 


r 


ses  of 
e  pain 

offers 

desire 

to  be 
lust  be 

is  the 
)rphine 
■aste  of 
medies, 
imation 
ibscess, 
Igic  at- 
ain  the 
pium  or 
in  anti- 
he  new 
ratively 
,    Thus 
benefits 
he  pains 
licrania, 
sciatica, 

cannabis 

nsomnia 

can  be 

St  opium 


—  33  — 
when  used  for  hypnotic  intent;  it  is  not  a  good  hyp- 
notic, as  it  produces  and  long  keeps  up,  in  many  per- 
sons, a  cerebral  excitation  incompatible  with  sleep; 
hence  where  other  analgesics,  as  antipyrin,  acetanilid, 
prove  to  be  sufficient  to  quell  the  pain,  they  should 
always  have  the  preference. 

2.  /nsomnia  due  to  ovenvork  of  the  brain  is  the 
insomnia  of  cerebral  hyperaemia.  Prolonged  study, 
constant  application  to  business,  literary  undertak- 
ings, speculative  enterprises,  etc.,  demanding  vigilant 
thought  and  entailing  much  worry  and  anxiety  are 
fruitful  sources  of  insomnia.  At  the  same  time,  ex- 
haustive mental  toil  may  be  carried  on  with  impunity 
provided  the  hours  of  sleep  be  not  interfered  with; 
provided  also  that  suitable  seasons  of  relaxation  and 
diversion  be  snatched  during  the  working  hours.  It 
is  unremitting  mental  toil  and  worry  that  kills. 

The  theory  that  during  mental  work  certain  dis- 
tricts of  the  brain  are  flushed  with  blood  is  consonant 
with  all  the  experiments  and  observations  whereby 
we  have  acquired  a  knowledge  of  the  physiology  of 
the  brain.  It  is  also  know.,  that  the  blood  supply  to 
the  brain  is  controlled  by  the  vaso-motors,  and  it  is  a 
legitimate  inference  that  in  the  insomnia  from  mental 
overwork  the  blood  vessels  of  the  cerebral  cortex  are 
overfilled  from  exhaustion  of  these  nerves,  or,  what 
means  the  same  thing,  from  exhaustion  of  the  tonicity 
of  the  blood  vessels. 

Doubtless  the  age  in  which  we  live  is  peculiar  in 

3  BBB 


.»^M .imini»«,.mu-  _,'^ijD 4,1,11  -'.  '?v»j..'!iMMI>*.<wakiuiMlliai.tiJi»MWiwpra« 


J 


—  34  — 
the  sense  that  multitudes  are  obliged  to  toil  harder 
with  their  brains  than  any  previous  race.     Never  be- 
fore, perhaps,  in  the  history  of  mankind,  did  arduous 
strife  and  competition  involving  the  higher  nervous 
centres  become  so  necessary.     The  present  genera- 
tion is  the  heir  to  all  the  acquisitions  of  the  past,  but 
these  have  been  an  ever  accumulating  burden    which 
is  almost  too  great  for  the  strong  to  bear    while  the 
weak  and  exhausted  must  succumb  beneath  the  load, 
though  the  latter  be  no  more  than  just  sufficient  to 
equip  its  possessor  for  a  fair  chance  in  the  struggle 

for  existence.  .     a   ^  a„  ^<.« 

It  has  been  proved,  however,  that  hard  study  can 
be  borne  with  impunity  provided  that  sufficient  physi- 
cal exercise  be  taken.    This  is  a  truth  which  the  liter- 
ary man  and  the  student  should  ever  have  in  mind. 
We  have  a  good  instance  of  this  in  the  life  of  the  la  e 
Frenchman,    Littr^,   one  of  the  most  indefatigable 
literary  workers  of  this  age.     His  habit  was  to  spend 
most  of  the  day  out  oi  doors  in  physical  recreation 
and  exercise;  and  he  only  began  his  studies  and  his 
writing  about  seven  o'clock  in  the  evening  when  he 
would  enter  his  library  and  pore  over  his  books,  ab- 
sorbed in  study,  or  bend  over  his  writing  desk,  work^ 
ing  without  cessation,  till  three  or  four  o  clock  in  the 
morning,  when,  yielding  to  fatigue,  he  would  seek  a 

few  hours*  refreshing  sleep. 

In  a  recent  spirited  publication,  Mary    Mana- 


li.iliiiWi*ia>«i 


Mana- 


—  35  — 
c^ine  *  has  traced  the  causes,  effects,  and  remedies  of 
mental  over-pressure  in  modern  life.  She  lays  great 
stress  on  the  want  of  gymnastic  training  in  schools, 
and  the  numerous  unhealthy  conditions  of  our  civiliza- 
tion. The  besetting  infirmities  of  the  age  are  "  cere- 
bral anaemia  "  and  "  nervous  exhaustion."  The  causes 
are  complex,  but  they  all  act  similarly,  "  by  producing 
irregularities  in  the  vascular  sphere,"  /.  e.,  by  impair- 
ing the  tonus  of  the  cerebral  blood-vessels.  "  When 
once  the  tone  of  the  blood-vessels  is  lost,  when  their 
nutrition  is  disturbed  and  the  circulation  no  longer 
responds  to  the  exigencies  of  normal  life,  phenomena 
of  dissolution  begin  to  manifest  themselves."  Doubt- 
less Mile.  Manac^ine  is  right  in  regarding  the  stimu- 
lants (tea,  coffee,  alcohol,  tobacco,  etc.)  in  which  the 
people  of  this  age  are  prone  to  indulge  as  being  large 
factors  in  producing  a  toneless  condition  of  the  cere- 
bral vessels,  but  exhaustion  by  overwork,  and  especi- 
ally by  worry,  are  doubtless  still  more  important 
factors. 

With  regard  to  the  influence  of  physical  over- 
work in  producing  insomnia,  the  explanation  may  not 
be  so  easy.  A  state  of  great  physical  fatigue  is  cer- 
tainly favorable  to  sleep,  but  over-fatigue  is  attended 
with  a  painful  aching  of  the  muscles,  which  causes  an 
excitation  of  the  cerebrum.  Germain  S^e  adds  as  a 
factor  the   accumulation  of  the  products  of  denu- 

*"  Le  Surmenage  Mentaledans  le  Civilisation  Moderne," 
Paris,  i8go. 


X  ■ 


M*M 


_  36- 

trition,  which  being  in  excess  in  the  blood,  act  as 
toxic  agents  and"  excite  the  cerebrum. 

With  regard  to  the  treatment  of  insomnia  by 
mental  overwork,  the  indicatio  causalis  first  demands 
attention.    The  student  must  curtail  his  studies,  his 
hours  of  work;  must  be  content  with  a  less  honorable 
standing  in  his  classes,  must  take  more  rest,  more 
recreation,  more  exercise.      These  injunctions  are 
especially  imperative  when  the  subject  of  insomnia 
is    a  growing    youth;    in  fact,   the    appearance    of 
insomnia,  or  dreamy,  restless,  unrefreshing  sleep  m 
children  should  generally  be  the  signal  for  removing 
them  for  a  time  from  school  and  prescribing  suitable 
sports  and  recreations,  a  course   of  gymnastics,  and 
other  measures  calculated  to  invigorate,  subdue  rest- 
lessness, and  procure  natural  sleep. 

Dr  Dukes,  of  Rugby,  is  of  the  opinion  that  boys 
under  ten  years  of  age  require  eleven  hours  sleep 
and  those  under  thirteen  need  ten  hours  and  a  half 
set  apart  for  this  purpose.* 

The  same  causal  indications  are  applicable  to 
the  man  of  business,  who,  when  once  he  finds  himself 
unable  to  sleep  of  nights  is  on  a  downward  scale, 
which  will  end  in  ruin  unless  he  can  pause  and  reform 
lis  habits.  Even  then  he  will  realize  the  /a«/» 
descensus  Averni,  while  to  retrace  his  steps-/«.  /a&or, 
hoc  opus  est.  One  of  the  most  annoying  forms  of  in- 
somnia among  business  men  is  this:  The  patient  goes 

♦Quoted  by  Macfarlane,  loc.  cit. 


ill 


ict  a? 

ia  by 
Hands 
8S,  his 
orable 
more 
IS  are 
iumnia 
ice    of 
leep  in 
moving 
;uitable 
cs,  and 
lie  rest- 

at  boys 
i'  sleep, 
i  a  half 

able  to 
himself 
■d  scale, 
1  reform 
B  facilis 
hie  labor, 
is  of  in- 
ent  goes 


-r*x\ 


—  37  — 
to  bed  and  falls  asleep  to  wake  up  in  an  hour  or  two 
with  his  mind  full  of  the  care  and  worry  of  the  day, 
and  then  there  is  no  more  sleep  all  night  long;  or  if 
sleep  returns  after  several  hours  of  wakefulness,  it  is 
a  disturbed,  dreamy  sleep  from  which  he  awakes 
tired,  jaded,  and  miserable.  This  kind  of  insomnia  is 
called  by  Germain  S^e  true  insomnia. 

The  following  table  is  modified  by  Macfarlane 
from  Friedlander,  and  contains  his  views  as  to  the 
best  division  to  be  made  of  the  twenty-four  hours  in 
the  matter  of  rest,  work,  and  sleep  : 


APE. 

HOURS   FOR 

Exercise. 

Work. 

Leisure. 

■    Sleep. 

7 

7 

3 

4 

lo 

8 

6 

4 

4 

10 

9 

5 

5 

4 

•    10 

10 

5 

6 

4 

9 

II 

5 

6 

4 

9 

IS 

5 

6 

4 

9 

13 

4 

7 

4 

9 

14 

4 

8 

3 

9 

»5 

4 

8 

3 

9 

Besides  making  the  endeavor  to  pursue  a  course 
of  life  the  reverse  of  that  which  he  has  been  pursuing, 
the  victim  of  insomnia  from  overwork  will  naturally 
for  a  time  seek  relief  from  some  of  the  safer  hypnot- 
ics, preeminently  among  which  is  sulphonal.     From 


nnfiiriiwiiiiiiiriii 


Jif 


-  38  - 
my  own  experience,  I  would  say  that  sulphonal  is  the 
king  of  hypnotics,  conferring  a  sleep  which  is  the 
most  like  natural  sleep  with  the  least  after-discomfort. 
Nor  does  the  continued  use  of  this  drug  seem  to  be 
attended  with  real  harm— at  least  with  any  such  evils 
as  follow  the  prolonged  use  of  morphine  or  chloral. 
I  know  one  business  man  who  has  been  in  the  habit 
of  taking  ten  grains  of  sulphonal  every  night  for  six 
months,  nor  has  he  yet  found  it  necessary  to  increase 

the  dose. 

Chloral  was  formerly  regarded  as  the  ideal  hyp- 
notic, and  in  many  cases  it  produces  a  sound  refresh- 
ing sleep  of  several  hours.  The  late  Dr.  J.  R. 
Nichols,  of  Haverhill,  told  me  in  1873  that  chloral 
had  been  a  boon  to  him— that  one  dose  of  ten  grains 
taken  at  bed  time  would  quite  banish  his  insomnia 
for  a  whole  week,  the  effect  not  wearing  away  for 

several  nights. 

In 'comparatively  tractable  cases  of  insomnia 
from  overwork,  a  tablespoonful  or  two  of  old  whisky 
at  bed  time  will  often  work  like  a  charm;  sleep 
speedily  ensues  and  lasts  many  hours;  with  many,  a 
glass  of  bitter  ale  has  a  still  better  effect. 

As  natural  sleep  may  be  hypothetically  regarded 
as  brought  about  by  certain  toxic  products  of  exercise^ 
and  as  muscular  exercise  is  known  to  be  more  pro- 
ductive of  these  hypnogenous  substances  than  intel- 
lectual, so  the  medical  adviser  may  very  properly  urge 
his  patient  to  perform  some  severe  muscular  work 


01 


Iftifmi'aliiiiii 


IMIWKtiiWiaWlW 


is  the 
is  the 
)mfort. 

to  be 
h  evils 
ihloral. 
e  habit 
for  six 
icrease 

il  hyp- 
efresh- 
J.  R. 
chloral 
1  grains 
isomnia 
way  for 

isomnia 

whisky 

;    sleep 

many,  a 

egarded 
ixercise^ 
)re  pro- 
an  intel- 
srly  urge 
ar  work 


—  39  — 
before  going  to  bed— a  long  walk  in  the  open  air, 
dumb-bell  exercise,  etc.  Many  a  victim  of  insomnia 
has  found  a  remedy  for  his'  infirmity  in  garden  work, 
joinery,  wood-sawing,  or  even  in  such  active  sports 
as  base-ball  and  lawn-tennis.  Sleep  is  much  more 
certain  to  follow  muscle-tire  than  brain-tire. 

As  the  leading  indication  is  to  induce  that  cere- 
bral torpor  which  is  the  necessary  antecedent  of  sleep, 
it  is  well  to  advise  the  insomnic  patient  to  avoid  all 
cerebral  excitants  in  the  evening.  He  should  not  in- 
dulge in  tea,  coffee,  tobacco  or  spirits,  with  the  excep- 
tion, perhaps,  of  an  occasional  draught  of  old  whisky  on 
going  to  bed,  as  above  stated;  he  should  refrain  from 
reading,  writing,  and  other  mental  labor.  Even  novel 
reading  (recommended  by  some  as  a  diversion)  is  of 
questionable  utility;  listening  to  the  reading  of  a  dull 
book  is  a  much  more  rational  expedient.  If  one  can 
succeed  in  breaking  the  train  of  thought  by  fixing  the 
attention  on  any  series  of  monotonous  souhds  (the 
singing  of  crickets,  the  roar  of  a  distant  waterfall,  the 
whistling  ot  the  wind  down  the'chimney,  etc.),  he  will 
often  before  he  is  aware  of  it  be  caught  in  the  toils  of 
Somnus. 

The  sleep  state  being  one  in  which  the  cerebral 
arterioles  are  contracted,  with  lessened  circulation  in 
the  encephalon,  the  artificial  production  of  this  con- 
dition would  seem  to  be  favorable  to  sleep,  and  much 
account  has  been  made  of  cold  applications  to  the 
head  made  with  the  intent  to  exsanguinate  the  brain; 


■:  'i 


LH.JJLUIJ.  .twff^iKrtMiiiaiw 


MIMMVMM^W- 


ill 


—  40  — 

hot  foot  baths  to  determine  blood  from  the  head,  and 
the  general  warm  bath  as  a  powerful  means  of  deriva- 
tion. Hammond  states  that  he  has  seen  the  applica- 
tion of  the  cold  douche  to  the  heads  of  refractory 
prisoners  bring  on  a  deep  sleep.  I  believe,  however, 
that  cold  to  the  head,  as  a  means  of  provoking  sleep, 
oftener  fails  than  succeeds,  and  I  have  even  known  it 
to  aggravate  the  insomnia.  Of  more  efficacy  is  bath- 
ing the  trunk  and  limbs  with  cold  water,  followed  by 
a  brisk  rubbing  to  induce  a  reactionary  glow;  stand- 
ing naked  on  the  cold  floor  a  few  minutes,  then  a 
hasty  rub-down  with  a  coarse  towel  or  flesh-brush, 
often  does  good  in  the  same  way  by  derivation.  The 
warm  bath  or  wet-pack  may  be  resorted  to  in  desper- 
ate cases. 

Macfarlane  gives  some  excellent  hints  for  the 
rational  treatment  of  this  kind  of  insomnia.  To  re- 
store tone  to  the  vaso-motor  system,  he  advises  a 
combination  of  nux  vomica  with  hydrobromic  acid. 

9     Acid  hydrobromic 3  vi. 

Tinct.  nucis  vom 3  ii. 

Aquam ad-    5  vi. 

M.  Sig.— A  tablespoonful  in  a  wineglassful  of  water 
twice  a  day,  before  meals. 

To  calm  and  strengthen  the  nervous  centres,  the 
patient  should  cultivate  the  habit  of  going  to  bed  at 
a  regular  hour,  and  of  rising  with  punctuality.  The 
bed-room  should  be  well  ventilated,  and  the  head 
raised  upon  a  high  pillow.     The  hours  for  eating  and 


i 

If 


!| 


•mm 


,  and 
eriva- 
plica- 
ictory 
vever, 
sleep, 
3wn  it 
bath- 
ed by 
stand- 
:hen  a 
brush, 
The 
lesper- 

■>T  the 
ro  re- 
nses  a 
cid. 


f  water 

es,  the 
bed  at 
,  The 
e  head 
ng  and 


—  4t  — 
drinking  must  be  laid  down  with  precision,  the  diet 
being  adapted  to  the  temperament  and  digestive 
powers,  the  last  meal  being  taken  some  three  hours 
before  going  to  bed.  The  plethoric,  whose  vascular 
tension  is  high,  do  best  without  alcohol  in  any  form, 
while  the  anaemic  are  often  benefited  by  a  moderate 
quantity  taken  with  the  food  to  promote  digestion 
and  a  "  night-cap  "  of  brandy  or  whisky  with  warm 
water  and  sugar.  On  account  of  its  stimulant  and 
derivative  action,  turpentine  in  thirty-drop  doses  at 
bed-time  is  a  powerful  aid  to  sleep.  It  is  easily  taken 
in  capsules.  If  it  is  found  necessary  to  resort  to 
hypnotics,  the  bromides  are  especially  serviceable,  the 
only  contra-indication  being  great  anaemia.  Mac- 
farlane  prefers  the  bromide  of  lithium,  as  it  contains 
a  half  more  bromine  than  the  potassium  bromide.  Its 
dose  is  from  lo  to  20  grains.  The  bromides  of  so- 
dium and  potassium,  which  are  in  most  frequent  use 
in  this  country,  are  given  in  doses  of  one-half  to  one 
drachm.  They  are  best  prescribed  in  syrup  and 
water,  a  full  dose  being  taken  a  few  hours  before 
bed-time  and  another  at  bed-time.  If  these  doses  do 
not  succeed  in  procuring  sleep,  they  may  be  asso- 
ciated with  ergot  of  rye  and  digitalis,  both  of  which 
are  stimulants  of  the  vaso-motor  centres.  Macfar- 
. lane's  favorite  prescription  is  as  follows:* 


^Macfarlane,  Insomnia  and  its  Therapeutics,  page  88. 


"  .      —  4a  — 

Q     Bromidi  llthli «^-  «'• 

F.xt.  cfRot  liqulil 5  »• 

Tinct.  digitalis '^'"'• 

Aqu«  chloroformi 5  xv. 

M.     siR.— Take  one-half  two  hour*  before  going  to  bea 
and  the  other  half  at  bed-time. 

3,  To  the  third   group  belongs  insomnia  con- 
nected with  a  disordered  state  of  one  or  mot  ■  organs. 
{a)  Morbid  States  of  the  Brain.-Thcs^  cause 
insomnia  by  interfering  with  cerebral  nutrition.    The 
changes  taking  place  in  the  brain  during  cerebral 
hyperamia  are  more  of  a  katabolic  than  of  an  anabo- 
lic character,  i>,  are  characterized  by  excessive  waste 
rather  than  normal  repair,  hence  are  antagonistic  to 
conditions  which   produce  sleep.     This  hypersem.a 
may  be  active  or  passive.     Active  hyperemia  is  due 
to  overwork  of  brain  (see  preceding  paragraph),  to 
alcohol  or  other  toxic  agents,  to  arterial  degeneration, 
to  exposure  to  intense  heat,  the  irritation  of  teethinji, 
to  tubercles,  syphilis,  etc.    The  passive  kind  is  gene- 
rally  due  to  organic  diseases  of  the  heart  and  lungs. 
Active  cerebral  hyperaemia  is  characterized  by  flush- 
ing of  the  face,  throbbing  of  the  temporals,  conges- 
tion of  the  retina,  suffusion  of  the  conjunctiva,  irrita- 
tability,   restlessness,  giddiness,  confusion  of  ideas, 
loss  of  memory,  etc.     In  passive  congestion,  stupor  is 
the  most  marked  symptom. 

In  the  active  form,  the  indication  is  to  lessen  the 
quantitv  of  blood  in  the  brain;  in  the  passive  form,  to 
increase  the  force  of  the  circulation  and  lessen  the 


tV 


10  bed 

con- 
•gans. 
cause 
The 
rebral 
inabo- 
waste 
Stic  to 
raemia 
is  due 
)h),  to 
ration, 
ething, 
!  gene- 
lungs. 
f  flush- 
;onges- 
,  irrita- 
ideas, 
;upor  is 

isen  the 
[orm,  to 
sen  the 


1 


—  43  — 
venous  supply.  The  first  indication  is  fulfil  led  by 
cold  to  the  head,  saline  purgatives,  leeches  to  the 
temples  or  outside  the  nose,  mustard  to  the  epigas- 
trium, the  constant  galvanic  current  for  two  minutes— 
the  positive  pole  being  over  the  sympathetic,  the  nega- 
tive on  the  nucha  (Hammond).  In  this  form  of  in- 
somnia, it  is  necessary  to  prescribe  the  bromides,  or, 
these  failing,  chloral.  In  the  passive  kind,  diuretics, 
saline  purgatives,  and  opiates  rather  than  bromides 
are  called  for. 

Alcohol,  which  is  contra-indicated  in  active,  is  of 
great  use  in  passive  hypertemia. 

The  cerebral  hyperoemia  with  which  wc  are  most 
familiar  either  soon  ends  in  recovery — the  patient 
gving  up  his  severe  tasks  or  his  excesses  in  eating  and 
drinking,  and  living  more  rationally— or  it  is  the  ava/U 
coureur  of  some  severe  and  generally  incurable  brain 
affection.  I  have  seen  children  suffer  from  flushed, 
hot  head,  vertigo,  headache,  irritability,  peevishness 
(i.e.,  the  symptom— cortege  of  hyperemia)  for  weeks 
before  becoming  the  victims  of  hydrocephalus.  I 
have  seen  it  the  precursor  of  apoplexy  in  the  aged, 
being  the  first  manifestation  of  atheromatous  degene- 
ration. It  may  be  the  first  symptom  of  general 
paralysis  of  the  insane  (periencephalitis). 

If  simple  hyperaemia  be  inimical  to  sleep,  h  fortiori 
inflammatory  states  of  the  cerebrum  or  its  membranes 
must  be  so.  The  insomnia  of  acute  meningitis,  of 
periencephalitis,  of  cerebritis,  is  sufficiently  familiar, 


'*Jfcrfii.i««».-.^. 


■^ifWif^hrif  y 


—  44  — 
and    even  when   the    usual     restlessness,  agitation 
and  delirium  give  place  to  the  .quiescence  of  coma, 
it  is  the  repose  of  paralysis  and  death,  rather  than 
refreshing  sleep,  that  is  witnessed. 

In  tuberculous  meningitis,  among  the  first  symp- 
tom.s  of  the  hyperemia  which  precedes  the  developed 
disease,  is  a  restless,  dreamy  sleep,  which  next  gives 
place  to  complete  insomnia. 

In  the  treatment  of  sleeplessness  due  to  inflam- 
matory conditions  of  the  cerebrum,  the  general  prin- 
ciples laid  down  under  cerebral  hyperemia  are  to  be 
carried  out.  Full  doses  of  chloral  with  bromides 
sometimes  give  brief  seasons  of  quiet,  if  not  product- 
ive of  real  sleep.  I  have  found  a  combination  of 
sulphonal  with  antipyrin  more  or  less  efficacious  in 
the  restlessness  and  delirium  of  meningitis. 

3     Sulphonal 

Antipyrin Sa  gr.  x. 

M.   Sig.— One  powder.     To  be  repeated  every  hour  till 
sleep  or  quiet  is  produced. 

This    combination     is    especially    indicated    in 

hyperpyrexia. 

Cerebral  tumors  are  a  cause  of  sleeplessness,  both 
from  the  inflammation  which  they  excite  and  the  pain 
which  is  a  constant  attendant. 

Anaemia  of  the  brain,  whether  produced  by  ex- 
cessive loss  of  blood,  profuse  discharges  from  the 
intestines,  from  chronic  abscesses,  etc.,  by  insufficient 
food,  by  exhausting  diseases  or  other  causes,  gives 


^-'"•■"■^'•— T-rrrn 


igitation 
)f  coma, 
ler  than 

St  symp- 
;veloped 
xt  gives 

)  inflam- 
;ral  prin- 
ire  to  be 
bromides 
product- 
lation  of 
acious  in 


y  hour  till 

icated    in 

ness,  botli 
i  the  pain 

ed  by  ex- 

from  the 

nsufficient 

ises,  gives 


^'^ 


—  45  — 
rise  to  sleeplessness  or  imperfect,  dreamy  sleep.  The 
explanation  of  this  insomnia  is  that  in  the  anemic 
there  is  not  only  an  exsanguinous  state  of  the  brain, 
but  a  vice  of  nutrition  resulting  from  insufficiency  of 
arterial  blood.  Germain  See  adds  another  cause 
which  applies  to  certain  cases;  the  local  oligiemias 
are  generally  due  to  emboli  or  obliterations  of  arteri- 
oles, and  the  failure  of  nutrition  goes  on  rapidly  to 
ramollissement,  the  initial  symptoms  of  which  are 
always  those  of  excitation. 

The  following  case  illustrates  the  general  treatment  of 
sleeplessness  due  to  anaemia: 

Mrs.  M.  B.;  aged  fifty;  mother  of  eight  children;  con- 
sulted me  in  May,  1883,  for  a  uterine  trouble  whose  principal 
manifestation  was  excessive  haemorrhages.  I  found  her 
weak  and  anaemic,  obliged  to  keep  her  bed  the  most  of  the 
time.  The  heart's  action  was  feeble;  there  was  a  systolic 
(anaemic)  bruit;  exertion,  excitement,  even  ordinary  food, 
would  often  bring  on  palpitations;  walking  or  an  attempt  to 
work  caused  breathlessness.  The  face  was  frequently 
flushed  (paresis  of  the  vaso-niotors^;  there  were  ringing 
noises  in  the  ears,  flashes  of  light  before  the  eyes,  and 
other  perversions  of  the  special  senses;  it  required  but 
little  exercise  of  the  eyes  to  tire  them— reading,  sewing,  etc., 
after  a  few  minutes  became  painful.  There  was  an  almost 
constant  headache,  with  mental  enfeeblement,  and  inability 
to  apply  the  mind  more  than  a  few  minutes  to  any  subject. 
The  insomnia  was  marked. 

I  found  a  uterine  polypus  to  be  the  cause  of  the  profuse 
haemorrhages;  this  I  removed  by  an  ecraseur,  thus  arresting 
the  loss  of  blood,  but  Mrs.  B.  suffered  for  months  from  the 
anaemic  symptoms  just  mentioned.     The  distressing  insom- 


[■■..i.ijii.j.'ai 


_  46  - 
nia  would  only  yield  to  opiates    with   draughts  of   whisky 
or  bitter  ale.     A  hypodermic  of  morphine  always  gave  most 
relief  but  this  was  seldom  resorted  to  through  fear  of  forming 
the  morphine  habit.     A  mixture  of  equal  parts  of  red  laven- 
der and  ammoniated  tincture  of  valerian,  dose  a  teaspoonful 
in  water,  often  had  a  marked  soothing  effect     Chloral  was 
avoided;  when  taken  formerly  while  Mrs.  B.  was  under  the 
care  of  another  physician  it  had  always  produced  excitement 
rather  than  quiet.     A  cordial  frequently  prescribed  consisted 
of  compound  tincture  of  lavender,  one  drachm;  tincture  of 
valerian,  one  drachm;  deodorized  laudanum,  twenty  drops; 
this  was  taken  at  bedtime.     After  a  few  weeks  had  gone  by, 
I  omitted  opiates  altogether,  giving  °">y/''«'7''f  J,;^,^!" 
at  night;  this  also  was  eventually  abandoned,  a  little  beef 
tea  or  fluid  beef  being  given  instead.     A  course  of  physical 
exercise  had  been  commenced-walks,  rides  in  the  open  air. 
parlor  gymnastics  which  powerfully  promoted  natural  sleep. 
Throughout  the  treatment,  nutrients  were  admin.stereQ  day 
and  night  in  as  large  quantities  as  could  be  assimilated;  thus 
always  between  meals  a  cup  of  beef  tea  or  «f -•*;«>  •»'»'' 
with   bovinine  was  given;  an  egg-nog  was  taken  the  first 
thing  in  the  morning  and  a  cup  of  milk  with  Mell.n  s  food 
and  a  spoonful  of  bovinine  at  midnight.      Eventually  the 
recovery  was  as  complete  as  could  bo  desired. 

I  have  on  record  numerous  cases  of  a  similar 
kind  where  the  distressing  insomnia  brought  on  by 
long-continued  discharges  has  yielded  to  suppression 
of  the  cause  and  the  plentiful  administration  of  stim- 
ulants and  nutrients.  . 

The  cerebral  anaemia  accompanying  aortic-val- 
vular disease  finds  expression  in  an  obstinate  insomnia, 
in  frequent  attacks  of  vertigo,  in  intellectual  disturb- 
ances and  in  a  profound  irritability  which  has  been 


11 


t^MMWBaaawaBWfe-^^wp'^ 


whisky 
e  most 
orming 
laven- 
poonful 
ral  was 
der  the 
itement 
)nsisted 
cture  of 
'  drops; 
one  by, 
y  or  ale 
tie  beef 
physical 
pen  air, 
al  sleep. 
;red  day 
ed;  thus 
rm  milk 
the  first 
in's  food 
lally  the 

similar 
t  on  by 
pression 
if  stim- 

•rtic-val- 

isomnia, 

disturb- 

las  been 


—  47  — 
•described  under  the  flame  of  irritable  weakness.  A 
similar  line  of  treatment  to  that  above  indicated  is 
needed,  but  the  main  reliance  must  be  in  opium  or 
hypodermic  morphine,  in  alcoholic  stimulants,  and  in 
nitro-glycerin.  It  is  hard  to  draw  the  line  between 
anaemia  and  passive  congestion,  but  it  must  be  re- 
membered that  in  aortic  disease  the  brain  is  in- 
sufficiently supplied  with  arterial  blood,  and  hence  is 
anaemic.  It  matters  not  if  the  cerebral  substance  is 
charged  with  venous  blood,  unless  the  subject  is  sup- 
plied with  plenty  of  arterial  blood  and  there  is  a  free 
circulation,  the  condition  of  the  cortical  cells  is  none 
the  less  one  of  anaemia. 

(i)  Degeneration  of  the  cerebral  arteries  is  a  cause 
•of  haemorrhage  or  softening,  and  one  of  its  common 
symptoms  is  troublesome  dreaming  or  insomnia, 
though  some  cases  are  characterized  by  morbid  som- 
nolence. Dreaming  in  advanced  life  is  generally 
regarded  as  suggestive  of  pending  apoplexy  (Mac- 
farlane).  In  the  treatment  of  this  kind  of  insomnia, 
the  general  principles  applicable  to  cerebral  anaemia 
are  to  be  observed.  Macfarlane  speaks  well  of  a 
mixture  of  henbane  and  camphor,  and  of  sumbul  and 
hops,*  and  professes  to  have  obtained  good  -esults 

*His  formula  are  as  follows: 

9     Spts.  chloroform |ss, 

Tinct.  sumbul, J  gs. 

Tinct.  lupuli 31. 

M.     Sig. — Two  teaspoonfuls  in   water  every  hour  till 
-sleep  is  procured. 


■I  ■;:  t 


f'i 

i  • 


ii'i 


li^ 


.         -48- 

9     Tinct.  digitalis •' ^^''• 

Tinct.  sumbul ^J; 

Tinct.  lupuli 5 ')• 

Aquam  ad '  '5- 

M.     Sig.— Take  one-half  at  bedtime  in  water,  and  repeat 
in  two  hours  if  required. 

from  sponging  the  nape  of  the  neck  with  hot 
water  and  from  the  application  of  mustard  plasters 
for  a  few  minutes  over  the  epigastric  region  or  the 
upper  part  of  the  spine. 

(<r)  Hysteria,  hypochondriasis,  mania,  melancholia, 
are  affections  due  to  disturbances  of  nutrition  of  the 
cerebral  cortex.  The  limits  of  this  treatise  will  not 
allow  a  separate  consideration  of  each  of  these  affec- 
tions, which  belong  to  the  category  of  neuroses  rather 
than  of  organic  diseases.  Nor  can  we  here  discuss 
the  general  subject  of  insanity  in  its  relation  to  in- 
somnia. 

The  sleep  in  hysteria  may  not  be  materially  lessened  in 
amount,  but  it  is  often  unrefreshing.  The  hysterical  subject 
wakes  in  the  morning  with  a  sense  of  physical  fatigue  or  of 
mental  depression  or  irritability.  Dr.  Mary  Putnam  Jacobt 
gives  us  an  ingenious  explanation  which  is  worth  repro- 
ducing. 

In  the  nervous  system,  and  especially  the  brain,  the 
waste  products  do  not  pass  directly  into  the  capillaries,  but 
into  the  lymphatic  sheaths  surrounding  the  arteries.  The 
circulation  of  the  lymph  current,  and  its  passage  from  the 
perivascular  to  the  sub-arachnoid  spaces,  is  regulated  by  the 
pulsations  of  the  brain  or  its  variations  in  volume,  by  which 
the  lymph  spaces  are  rhythmically  compressed.     The  braia 


figgHlgfftggggeUhii^^^mSSSf^ 


repeat 

h  hot 
lasters 
or  the 

cholia, 
of  the 
'ill  not 
i  affec- 
,  rather 
discuss 
n  to  in- 

sened  in 
I  subject 
lie  or  of 
n  Jacobi 
h   repro» 

rain,  the 
ries,  but 
es.  The 
from  the 
id  by  the 
by  which 
"he  brain 


—  49  — 
pulsation   is  composed  of  three  factors:   The  arterial  pulse 
wave,  the  respiratory  wave,  and  the  vascular   wave      The 
respiratory  wave  results  from  the  aspiration  of  venous  Wood 
from  the  bra.n  during  respiration  and  the  obstruction  to  its 
flow  dunng  expiration.     The  vascular  wave  advances  like  a 
peristaltic  movement,  and  consists  in  rhythmic  contractions 
and  dilatations  of  the  arterioles,  apart  from  the  cardiac  pulse 
and  dependent  on  intermittent  vaso-motor  influences.     This 
vascular  wave  is  said  by  Buckhardt  to  be  much  more  regu- 
ar  during  sleep  than  in  the  waking  period  and  constitutes 
the  Pnncipa  motor  mechanism  for  removing  waste  products 
through  the  lymphatic  channels.     If  it  be  true  that  this  vas- 
cular wave  IS  of  more  importance  in  the  lymph  circulation 
•n  the  brafn  than  either  the  pulse  or  respiratory  wave,  it  is 
clear  that  any  disorder  of  the  va«o-motor  centres  which  gov- 
em  It  may  greatly  disturb  the  removal  of  waste  products  by 
nterfenng  with  the  normal  development  of  such  a  wave 
If  for  example,  the  normal  intermittence  of  vaso-motor  iml 
pu  les  becomes  exchanged  for  a  permanent  tonus,   the  dia- 

swelling  of  the  hemispheres  by  which  the  ventricles  ar.  com- 
pressed. There  would  remain  the  variations  in  volume  due 
to  the  cardiac  systole  and  diastole,  but  in  sleep  these  are  re- 
duced to  a  minimum.  Hence  in  any  person  subjected  to  ab- 
normal vaso-motor  irritations  must  exist  an  imperfect 
removal  of  waste  products  from  the  brain  during  sleep  and 
therefore  imperfect  refreshment  by  the  great  restorer.* 

The  above  considerations  are  not  to  be  regarded 
in  the  light  of  mere  speculation,  but  are  legitimate 
deductions  from  accurate 'experimental  observations 
by  Buckhardt  and  Meynert.  The  same  causes  of  im- 
perfect  sleep  are  doubtless  more  or  less  operative  in 

*"miV*"*  *"**  ^™'"  Tumor,  New  York,  i888. 


—  5°  — 
neurasthenia,  and  in  all  forms  of  functional  brain  dis- 

^^'%d)  It  is  but  natural  that  such  painful  affections 
as  spinil  meningitis  and  myelitis,  and  locomotor  ataKa 
in  its  acute  stages  and  painful  crises  should  cause 
'llplessness,  only  allayed  by  ^en-bi^g  the  seat  of 
pain  with  anodyne  narcotics,  and  only  removed  by 
^uccessfullv  combating  the  disease. 

Tntipyrin.  or  acetanilid,  in  ten  to  fifteen  grain 
doses  frequently  repeated  till  its  sedative  action  is  ex- 
perTenced%ften  has  a  charming  effect  m  jreheving 
Ta"  irrit;tion,  fever,  and  thus  P-^^-^.  f  f f  J^, 
Ldicine  probably  has  given  so  much  rdief  in  these 
forms  of  spinal  disease  as  antipyrin,  but  the  doses 
mn«;t  be  laree  and  continuous. 

"in  one  case  of  locomotor  ataxia  with  lightning 
.ains  that  came  under  my  observation  acetaml.d  in 
doses  of  ten  grains  an  hour  never  failed  to  subdue  the 
oa  n  °n  the  course  of  a  few  hours,  though  the  patient 
E  became  restive  under  the  pain  and  demanded  a 
hypodermic  of  morphine. 

INSOMNIA   OF   RESPIRATORY   ORIGIN. 

Under  this  head  we  propose  to  consider  chiefly 
dyspnoea  and  cough  in  their  relation  to  insomnia  In 
Se  diseases  of  the  respiratory  organs,  pain  and  fever 
:  eTnfluential  along  with  other  factors  j"  the  Pro<iu. 
tion  of  an  insomnia  which  naturally  yields  when  the 
acuteness  of  the  disease  subsides.    In  pleurisy  and 


fc 


*.«ti 


1  dis- 

:tions 
ataxa 
cause 
;at  of 
ed  by 

grain 
I  is  ex- 
lieving 
p.  No 
I  tliese 
;  doses 

jhtning 
nilid  in 
due  the 
patient 
mded  a 


r  chiefly 
inia.  In 
ind  fever 
;  produc- 
when  the 
irisy  and 


—  St- 
even in  pneumonia  the  pain  may  be  severe  enough  to 
require  an  opiate,  and  even  a  hypodermic  of  mor- 
phine; with  regard  to  pneumonia,  I  think  that  we 
should  be  chary  in  the  use  of  opiates,  no  matter  how 
severe  the  cough  or  the  pain  may  be.  This  I  say  from 
experience,  without  formulating  any  theory  in  explana- 
tion. I  know  that  the  pain  of  this  disease  often  yields 
to  a  sinapism  or  hot  poultice,  to  a  full  dose  of  quinine 
with  extract  of  aconite,  and  to  repeated  full  doses  of 
veratrum  viride.  My  friend,  Dr.  B.  W.  Bartlett  of 
Rowley,  has  great  faith  in  the  application  of  a  dozen 
leeches  to  the  chest  in  the  onset  of  pneumonia,  with 
hot  water  fomentations  prolonged  for  hours  after- 
wards; the  pains  are  alleviated  and  rest  promoted 
without  the  assistance  of  any  anodyne. 

The  dyspnoea  of  respiratory  disease  (apart  from 
cardiac  complications)  is  either  spasmodic  or  obstruc- 
tive. Spasmodic  dyspnoea  is  exemplified  in  false 
croup,  in  bronchial  asthma,  and  in  true  asthma.  In 
all  the  bronchial  affections  of  children  a  neurosal 
element  can  be  clearly  traced;  this  is  especially 
noticeable  in  the  paroxysmal  cough  and  dyspnoea  of 
whooping-cough. 

Respiratory  dyspnoea  when  not  due  to  spasm 
may  be  the  result  of  obstruction:  a,  by  exudation 
within  the  pulmonary  parenchyma  as  in  pneumonia- 
d,  by  exudation  within  the  pleural  cavity  (pleurisy)-  c 
by  swelling  of  the  bronchi  and  profuse  bronchial  secre- 
tion (acute  bronchitis,  especially  capillary  bronchitis) 


i 


"^! 


—  S3   — 

The  treatment  of  insomnia  from  any  of  the  above 
conditions  resolves  itself  ^"^0  the  endeavor  as  far  as 
possible,  to  alleviate  or  remove  ^he  cause^  Bronchms 
should  be  treated  in  the  earlier  stages  by  medicmes 
whth  aUay  febrile  excitement.  vaso-constr.cUon  and 
roasm  in  short,  by  remedies  ^vhich  diminish  the  pen- 
pC  esistan<;es^mongthese.Ithink  antim^^^^^^^^^^^^^^ 
ipecacuanha,  veratrumviride,  and  lobeha  mflata  st.ll 

hold  the  first  place. 

5    Antimon.  et.  pot.  tart S""'  '" 

Nitrate  of  potassium ^  J • 

Mucilage  vel.  aquas •'•J 

M     Sin     A  tablesooonful  every  two  hours. 

■  '.  3ij. 

3    Vin.  Ipecac . 

Mucilage u  "  ,. 

M.    Sig.    A  tablespoonful  every  two  hours. 

3     Fluid  ext.  verat  virid |*f- 

Aquse 

M     Sig     A  teaspoonful  every  hour  or  two. 

When  the  bronchial  secretion  is  well  established 
the  antimonial  and  other  depressant  "J^  ^^  ;""2n 
and  carbonate  of  Ammonia  substituted  in  five  grain 
doses  A  small  dose  of  chloral  may  be  admi^.ble  at 
bed  time-  when  the  secretion  is  very  profuse  an 
emetirof 'sulphate  of  zinc  or  turpeth  njne-  -^^^^^^^ 
given  as  Macfarlane  recommends.     After  the  tubes 

;:^combination  of  tarur  emetic  and  «no;pW«;^ 

grain  every  hour  till  the  oppressive  cough  ceases,  i.  one  to 
which  I  have  often  had  occasion  to  resort. 


bove 
ir  as 
:hitis 
cines 
and 
peri- 
ials,* 
I  still 


ilished, 
>mitted 
e  grain 
sible  at 
use  an 
maybe 
e  tubes 

phlne,  ■ft 
is  one  to 


—  53  — 

are  emptied,  a  dose  of  urethan  (gr.  xxx)  of  paralde- 
hyd  ( 3  j.),  or  even  a  Dover's  powder  (gr.  x)  may 
be  administered. 

The  general  principles  of  treatment  of  neurosal 
dyspnoea  are  the  same,  whatever  name  may  be  appli- 
cable to  the  particular  manifestation.  Antispasmodics 
and  anaesthetics  are  always  indicated;  in  attacks  of 
spasmodic  asthma  and  laryngismus  stridulus,  a  few 
drops  of  the  anaesthetic  mixture  A.  C.  E.,  inhaled 
from  a  sponge  or  towel,  always  give  relief. 
'    ;^lcohol ,p^„ 

J'!'"™^"^'" 2  parts. 

Ether „        . 

Mix.  3parts. 

Nitrate  of  amyl,  gtt.  iii,  inhaled  from  the  palm 
of  the  hand  frequently  gives  instant  relief;  chl,  ral 
hydrate  with  potassium  bromide  in  full  doses  is  slower 
m  .ts  action,  but  more  permanently  reduces  inordi 
nate  reflex  excitability.     With  some  patients  hypo- 
dermic  morphia  is  a  necessity.   In  laryngismus  stridu- 
lus or  spurious  croup  an  emetic  is  generally  sufficient 
speedily  to  relax  the   spasmodically  tightened   air- 
tubes     Of  all  emetics  the  turpeth  mineral  is  the  one 
which  in  my  practice  has  yielded  the  most  satisfactory 
results.     Parke,  Davis  &  Co.  make  tablets  of  this  salt 
containing  two  grains,  which  are  very  convenient. 
A  more  frequent  cause  of  insomnia  is  cough 
I  have  not  space  to  review  the  various  pathologi- 
cal conditions  productive  of  cough  and  supplement 


\r 


—  54  — 
such  review  by  therapeutical  hints.     The  most  that  I 
can  do  is  to  touch  upon  a  few  points  of  practical  im 
portance  in  connection  with  the  relation  ( <  insomnia 

to  cough.  u        .•     ♦ 

In  the  early  stages  of  consumption,  the  patient 
may  be  tormented  with  a  teasing  cough  which  is  for 
the  most  part  dry.     Every  physician  is  familiar  with 
such  cases.     The  physical  signs  are  obscure;  at  the 
most  there  is  a  slight  dulness  under  one  or  both  clavi- 
cles, but  there  is  a  little  febrile  movement  every  day 
with   failure  of  appetite  and  strength.     This  cough 
indicates  an  irritation  of   the  respiratory  organs  by 
bacilli  and   tubercles,  and  is  not  alleviated  by  the 
ordinary  expectorants.     Here  calmatives  and  seda- 
tives  with  counter  irritation  do  little  or  no  good.     A 
pill  of  codeia,  one  grain,  at  bedtime  will  sometimes 
effectively  allay  irritation  and  produce  sleep.     Chloral, 
bromide  of  potassium,  cannabis  Indica,  hyoscyamus 
and  belladonna  may  all  be  tried,  with  doubtless  sonie 
alleviation  at  first;  while  nothing  will  so  promptly 
relieve  and  so  thoroughly  as  morphine.    The  latter 
medicament  may  be  combined  with  dilute  hydrocyanic 
acid,  chloroform,  and  tolu,  as  follows: 

9     Chloroform g".  xvj. 

Morph.  sulph •' 8'- »)• 

Acid  hydrocyanic,  dilute gtt.  xxj. 

Syrup  tolu 5  ')• 

M.   Sig.-A  teaspoonful  at  bedtime  and  at  midnight 
when  the  cough  is  troublesome. 


\r 


:hat  I 
i\  im 
jmnia 

atient 
is  for 
r  with 
at  the 
clavi- 
ry  day 
cough 
ins  by 
by  the 
i  seda- 
od.     A 
letimes 
Chloral, 
cyamua 
is  some 
romptly 
i  latter 
ocyanic 


midnight 


—  55  - 

A  spray  of  liquid  albolene  and  menthol  used  by 
a  hand  atomizer  will  sometimes  allay  the  tickling  in 
the  upper  air  passages  which  seems  to  be  the  point  of 
departure  of  the  cough.      . 

3     Liquid  vaseline t: 

Menthol ,' 

J  S8. 

M.   For  the  spray-producer, 

Such  patients  are  often  benefited  by  full  doses  of 
Rock  and  Rye  "  on  going  to  bed. 

I  have  seen  good  results  from  small  blisters  ap- 
plied  to  the  upper  part  of  the  chest,  or  from  painting 
the  upper  thorax  with  tincture  of  iodine  till  the  skin 
begms  to  peel. 

Of  the  various  cough  troches,  there  is  one  made 
by  Parke,  Davis  &  Co.  and  other  of  the  pharmacists, 
contam.ng  a  little  cubebs  with  extract  of  licorice 
which  has  given  satisfaction  in  my  practice.  I  have 
seen  somewhere  the  advice  to  paint  the  throat  with 
liquor  cocaine;  this  expedient  I  have  never  tried,  but 
I  should  think  that  it  might  produce  some  temporary 
alleviation,  ■' 

In  the  later  stages  of  phthisis  when  expectora- 
tion IS  profuse,  it  is  not  always  safe  to  arrest  the 
cough  by  narcotics  given  at  bed-time;  there  is  so 
much  secretion  from  the  vomicae  and  inflamed  mucous 
membrane  that  frequent  fits  of  coughing  are  neces- 
sary to  remove  muco-pus  and  prevent  asphyxia  In 
such  cases  an  emetic  of  sulphate  of  zinc  sometimes 


/ 


-56  - 
has  a  salutary  effect  in  clearing  the  bronchi  and  per- 
mitting a  few  hours'  quiet  sleep.  I  have  found  bella- 
donna serviceable  in  restraining  secretion;  this  may 
be  prescribed  in  the  form  of  a  pill  of  atropine,  jU^\\ 
grain,  night  and  morning.  Senega,  turpentine,  tar, 
sulphur,  and  carbonate  of  ammonia  have  a  reputation 
when  there  is  copious  expectoration,  and  the  spray  of 
ipecacuanha  wine,  as  recommended  by  Murrel,  may 
be  tried  to  advantage. 

The  syrup  of  tar,  with  carbonate  of  ammonia, 
and  the  Compound  Pine  Expectorant  of  P.,  D.  &  Co., 
are  preparations  which  have  become  popular. 

The  catarrh  is  a  product  of  bronchial  congestion 
provoked  and  kept  up  by  the  presence  of  tubercles, 
and  cannot  be  much  modified  while  active  tuberculiza- 
tion exists. 

In  the  teasing,  paroxysmal  cough  of  pertussis, 
full  doses  of  antipyrin  or  acetanilid  have  proved  of 
great  efficacy. 

Q     Acetanilid 3»8. 

Divide  in  cliart,  No.  vi. 

Sig.  Give  one  powder  every  four  hours  night  and  day, 
and  keep  up  the  treatment  for  a  week  or  even  a  fortnight. 

For  a  child  of  lo  years,  the  five-grain  tablets  are 
very  convenient.  The  one- grain  tablets  (one  every  4 
hours)  may  be  prescribed  for  infants. 

Antipyrin,  phenacetin,  or  exalgin  in  equivalent 
doses  may  be  given  instead  of  acetanilid.  I  have 
given  infants  two  years  old  grain  doses  of  antipyrin 


/ 


nd  per- 
l  bella- 
lis  may 

ne,  tar, 
utation 
pray  of 
el,  may 

imonia, 
.  &  Co., 

igestion 
bercles, 
srculiza- 

ertussis, 
oved  of 


and  day, 
tnlght. 

blets  are 
•  every  4 

>juivalent 

I   have 

antipyrin 


—  57  — 
«very  two  hours  in  whoopintf-cough,    and   seen    the 
paroxysms    markedly     diminish    in    fre<iuency    and 
violence  under  this  treatment.    The  quantity  of  either 
ant.pynn  or  acetanilid  may  be  increased,  if  necessary 
till  a  decided  constitutional  impression  is  produced. 

I  used  to  give  bromide  of  pota.ssium  in  whoop, 
mg-cough,  with  or  without  chloral,  and  have  seen 
duced''   ™'*'^"*'°"   °^  *^^  paroxysms   thereby    pro- 

8     Pot,  hromid 3  j; 

Hyd.  chloral 3  gg 

■  Syr.  tolu ;.;;    jiij. 

M.  Sig.  A  teaspoonful  every  hour  till  aleep  is  pro- 
duced.     For  a  child  5  years  old.  *^        ^ 

THE    INSOMNIA    OF    HEART    DISEASE     AND     ITS     TREAT- 

MENT. 

In  aortic  disease  (constriction,  insufficiency 
aortitis,  aneurism)  the  arterial  outflow  is  embarrassed 
and  unless  the  compensatory  hypertrophy  be  .sufficient 
through  the  extra  power  thereby  given  to  the  heart- 
muscle  to  ensure  filling  of  the  arteries,  the  whole 
organism  suffers  in  its  nutrition  and  function,  and  no 
department  more  than  the  cerebrum.  Hence  the 
insomnia  of  aortic  disease  is  essentially  the  insomnia 
of  anaemia. 

But  there  is  generally  more  than  this.  The 
blood-depurating  organs  participate  in  the  general 
disturbance  of  nutrition,  and  imperfectly  eliminate 
waste  elements,  and  to  the  poverty  of  arterial  blood 


X 


y 


_  58  - 

in  the  system  is  added  a  more  or  less  toxic  condition< 
of  the  blood. 

Now  that  we  are  better  acquainted  with  the  con- 
ditions productive  of  aortic  affections,  we  know  that 
the  latter  are  very  often  the  expression  of  that  wide- 
spread disease  of  the  arteries,  arterio-sclerosis;  the 
victim  of  heart  disease  has  interstitial  nephritis,  and,, 
sooner  or  later,  becomes  anaemic. 

A  peculiar  state  of  mental  irritability  generally 
accompanies  aortic  disease,  and  may  even  give  rise  to- 
a  form  of  insanity. 

Among  the  symptoms  of  aortic  disease  are  par- 
oxysmal crises  of  dyspnoea  (cardiac  asthma),  especi- 
ally frequent  at  night,  and  attacks  of  precordial  pain, 
which  arrest  the  patient  in  his  occupation;  if  he  is 
walking,  compel  him  to  stop  and  lean  against  some 
support. 

The  pain  in  the  earlier  stages  of  aortic  disease  is 
characterized  by  momentary  pangs,  and  is  the  result 
of  exertion;  in  extensive  atheromatous  disease  of  the 
aorta  involving  the  coronary  arteries,  it  is  of  a  much 
more  intense,  prolonged,  and  agonizing  kind,  and  is 
true  angina  pectoris. 

In  the  treatment  of  the  insomnia  of  aortic  dis- 
ease, the  mechanism  by  which  this  insomnia  is  brought 
about  must  be  kept  in  mind.  A  leading  indication  is 
to  promote  the  arterial  blood  supply  of  the  brain,  and 
thus  improve  its  languishing  nutrition.  The  pure 
hypnotics,  chloral,  paraldehyd,  sulphonal,  are  rarely 


y 


:onditioni 

the  con- 
low  that 
lat  wide- 
osis;  the 
'itis,  and, 

ajenerally 
ire  rise  to 

are  par- 
),  especi- 
dial  pain, 
if  he  is 
some 


» 
nst 


disease  is 
:he  result 
se  of  the 
)f  a  much 
id,  and  is 

ortic  dis- 
s  brought 
lication  is- 
}rain,  and 
The  pure 
ire  rarely 


—  59  — 
useful,  while  there  is  one  remedy  which  is  of  sovereign 
efficacy,  which  energizes  the  circulation  and  relieves 
dyspnoea  and  pain.  "Opium,"  says  Gabler,  "deter- 
mmes  a  particular  excitation,  gives  fullness  to  the 
pulse,  raises  the  temperature,  augments  the  injection 
of  the  teguments  and  promotes  diaphoresis.  The 
countenance  brightens,  the  eyes  become  brilliant  and 
moist,  the  pupils  contracted,  the  skm  covered  with 
perspiration,  then  quiet  sleep  ensues." 

The  morphine  may  be  associated  with  atropine 
and  administered  hypodermically,  and  for  this  pur- 
pose the  compressed  tablets  (sulph.  morph.,  %  grain; 
sulph.  atropia,  ^J^  grain)  are  very  useful.  It  may  be 
necessary  to  resort  to  these  injections  very  often - 
every  day.  with  gradually  increasing  dose-and  there 
will  be  the  risk  of  rendering  the  patient  a  morphio- 
maniac,  but  it  is  a  choice  between  two  evils  in  an  in- 
curable disease  steadily  becoming  worse. 

As  to  the  question  of  the  applicability  of  digitalis 
m  aortic  disease,  there  is  considerable  difference  of 
opmion.  A  weak,  struggling  heart  always  seems  to 
demand  this  potent  remedy,  but  practically  it  has  not 
been  found,  at  least  in  the  earlier  stages  of  aortic 
disease,  to  be  so  beneficial  as  nitro-glycerin  and  the 
vaso-dilators.  The  reason  is  probably  thii^,  as  stated 
byHuchard:  that  the  "cardio-aortic"  patient  is  not 
only  suffering  from  anaemia,  but  from  a  poisoned  con- 
dition of  the  blood— the  dyspnoea  and  the  precordial 
anguish  are  often  toxic,  and   are  the  expression    of 


■iwililW 


—  6o  — 

spasmodic  constriction  of  the  arterioles,  a  condition 
which  is  favored  by  digitalis,  whose  tonic  action  ex- 
tends to  the  whole  arterial  system.  Under  the  in- 
fluence of  this  drug,  the  arterioles  are  tightened 
rather  than  relaxed,  while,  on  the  contrary,  nitrite  of 
amyl  and  nitrite  of  soda,  and  especially  nitro-glycerin 
systematically  and  perseveringly  administered,  relax 
the  arterial  system,  thus  invitinjr  rather  than  opposing 
the  sanguineous  outflow,  and  lightening  the  work 
of  the  heart.  To  these  remedies  may  be  added 
an  exclusive  diet  of  milk,  which  by  its  nutrient  pro- 
perties, its  easy  digestibility,  its  absence  of  toxic  ex- 
tracts, and  its  marked  diuretic  action  wonderfully 
promotes  the  comfort  and  well-being  of  these  "  cardio- 
arterial "  subjects. 

The  insomnia  of  mitral  disease,  as  well  as  of  a 
number  of  other  forms  of  heart  disease,  is  closely 
associated  with  the  dyspnoea  that  attends  those  affec- 
tions, and  this  is  a  convenient  place  for  a  few  more 
general  considerations  on  cardiac  dyspnoea  and  its 
treatment.. 

CARDIAC    DVSPNCEA. 

When  we  consider  the  frequent  coincidence  of 
cardiac  lesions  with  dyspnoea,  we  cannot  regard  it  as 
surprising  that  in  the  infancy  of  pathological  anatomy 
Rostan,  noticing  in  a  large  number  of  aged  patients 
at  the  Saltpetrifere,  recorded  as  asthmatic,  definite 
lesions  of  the  heart  and  aorta,  should  have  concluded 
that  asthma,  as  an  idiopathic  malady,  does  not  exist. 


idition 
on  ex- 
the  in- 
htened 
;rite  of 
;lycerin 
I,  relax 
(posing 
;  work 
added 
nt  pro- 
ixic  ex- 
lerfully 
cardio- 

as  of  a 
closely 
e  affec- 
w  more 
and  its 


ence  of 
ird  it  as 
matomy 
patients 
definite 
ncluded 
ot  exist, 


—  6i  — 

being  always  symptomatic  of  diseases  of  the  CL.uIa- 
tory  organs. 

When  we  inquire  into  the  conditions  of  cardiac 
dyspnoea,  we  find  them  to  be:  Mitral  stenosis  and  in- 
sufficiency; myocarditis  and  fatty  degeneration  of  the 
heart-muscle;  dilatation  of  the  ventricles  and  aorta, 
from  whatever  cause;  and  uncompensated  lesions  of 
the  valves  of  the  aorta  and  pulmonary  artery. 

In  the  case  of  most  of  the  above  causes,  the 
modus  agendi  is  very  simple;  the  dyspnoea  i's  of 
mechanical  origin,  being  the  result  of  pulmonary 
stasis;  the  heart  is  unable  to  clear  the  capillaries  in 
the  sphere  of  the  lesser  circulation. 

Most  persons  affected  with   mitral  disease  are 
short-breathed;  when  at  rest  they  have  little  or  no 
dyspnoea,  but  they  immediately  suffer  for  want  of 
breath  when  they  attempt  any  considerable  exertion, 
as  gomg  up  a  flight  of  stairs  or  ascending  a  hill.     In 
the  earliest  stages  of  mitral  insufficiency  the  dyspnoea 
may  be  hardly  noticed,  except  when  the   heart  is 
severely  taxed,  as  in  the  effort  of  running;  in  advanced 
stages  the  difficult  breathing  becomes  permanent  on 
account  of    the    constant  pulmonary  engorgement. 
There  is  nothing  asthmatic  about  this,  for  the  essen- 
tial characteristic  of  asthma  is  the  intermittent  and 
paroxysmal  character  of  the  dyspnoea. 

The  difficult  breathing  attending  aortic-regurgi- 
tant  disease,  aortitis,  dilatation  of  the  heart  cavities 
and  aorta,  fatty  degeneration,  etc.,  is  generally  parox- 


I 


—  62  — 

vsmal  in  its  nature,  and  the  attacks  come  on  in  the 
n  ght  time  rather  than  in  the  day.    The  explanat  on 
^en  by  Professor  S6e  was  formerly  -garded  as  sa  - 
isfactory:  "The  blood-stasis  in  the  lungs   which  is 
ti:  first'cause  of  the  oppression,  manifests  itself  gen- 
erally in  the  night  time,  because  it  is  favored  by  de 
clivity  that  is,  by  the  dorsal  decubitus;  to  this  first 
cauJ'a^  added  others  which  contribute  much  toward 
;      ok"  g  the  explosion  of  those  attacks  of  resf^^^^^^ 
tory  distress  which  often  present  a  f«'^'«>dable  inten- 
sUy     These  purely  mechanical  causes  are:  Disten- 
sfon  of  the  stomach,  and  the  forcing  upward  of  the  dia- 
phragm which  notably  diminish  the  respiratory  area, 
Sy'irsufficient  for  h.matosis.    Add,  as  acce^ory 
causes   bronchial  catarrh  and  frequent  concomitant 
Tphysema,  and  you  have  the  entire  -t  «  ^gy  o  ^[^^^ 
oxysmal  dyspnoea  linked  to  affections  o  the  hea^t 

The  dyspnoea  due  to  dilatation  of  the  heart,  ac 
cording  to  Professor  S6e,  is    ■  no.t  always  continuous 
though  there  are  paroxys: :.      .acerbations,  and  that 
due  to  fatty  degeneration  is  „«,•  ^.«.m,"  presenting 
som^^mes  r'eal  paroxysms  of  distress  and  suffocation 
at  the  same  time  that  careful   examination  of  the 
Igs  does  not  reveal  any  morbid  signs;  there  is  not. 
the  least  acceleration  of  the  breathing,  or  any  appar- 

-^S;r:rS^^-espiratory  plexuses 


•Maladies  du  Coeur.  etc.,  1883.  p.  30. 


-*i»^,-.>;^^,,,,^^  ^ 


in  the 
mation 

as  sat- 
rhich  is 
5lf  gen- 
[  by  de- 
bts first 
1  toward 

respira- 
e  inten- 

Disten- 

tbe  dia- 
Dry  area, 
iccessory 
comitant 
jr  of  par- 
beart."  * 
lieart,  ac- 
ntinuous, 
and  tbat 
iresenting 
uffocation 
m  of  tbe 
ere  is  not 
iny  appar- 

y  plexuses 


-63- 
^f  nerves,  as  Peter,  Trousseau,  etc.,  teach,  has  been 
beheved  to  have  some  share  in  the  respiratory  dis- 
tress; and  the  magical  relief  conferred  by  a  hypodermic 
injection  of  morphine  or  other  calmative  before  even 
the  pulmonary  congestion  or  oedema  is  mitigated  has 
been  cited  in  confirmation  of  this  doctrine 

Henri  Huchard  has  of  late  written  much  and 
ucidly  on  the  paroxysmal  dyspnoea  of  aortic  regurgi- 
ation  and  aortitis.  The  dyspnoea  of  ao.litis  is,  liL 
that  of  mitral  disease,  at  the  first  a  dyspnoea  of  effort 
coming  on  during  rapid  walking,  lifting,  etc  •  it  is 
paroxysmal  and  often  intense,  rarely  spontaneous 
Later  on  in  the  disease  the  attacks  come  on  in  the 
night  time,  often  reproducing  themselves  with  great 

ST'h'"  '""V^"  P'^'^"'  '^  obliged  to  pas?  the 
night  in  his  arm-chair.     Huchard  regards  this  "  aortic 
pseudo-asthma  "  as  due  to  arterial  hypertension  which 
augments  by  the  recumbent  posture  and  under  the 
nfluence  of  sleep,  as  also  by  walking,  and  under  the 
influence  of  movement."    The  cause  of  the  dyspnoea 
.s  "  mechanical,"  as  Professor  S^e  taught,  butToHn 
the  same  sense  as  he  taught,  for  in  Huchard's  view 
we  have  to  do  with   "peripheral  resistances,"  and 
"spasm      of  the  blood-vessels.     If,  says  Huchard 
distension  of  the  stomach  has  anything  to  do  with  th^ 
paroxysmal  dyspnoea,  abstinence   from   the  evening 
meal  or  a  very  frugal  repast  ought  to  keep  the  patient 
free  from  his  nocturnal  attack;  this  is,  however,  sure 
to  come,  whether  he  eat  little  or  much. 


If 


—  64  - 

This  dyspnoea,  Huchard  amrms,  is  also  of  toxic 
origin.      Experiments  like  the    following    seem    to 
demonstrate  this:     He  injects  under  the  sVm  of  a 
guinea-pig  normal  urine;    death   ensues  m   several 
days     He  injects  the  same  quantity  of  urme  from  a 
woman  affected  with  arterio-sclerosis  of  the  heart  and 
aorta,  and  the  guinea-pig  scarcely  suffers  any  detr.^ 
ment.    This  proves,  he  says,  that  the  blood  of  h.s 
patient  was  poisoned  by  the  products  of  d'sassimilar 
tion  which  the  kidneys,  already  impermeable  by  the 
fact  of  the  aortitis  and  a  commencing  arteno-sclero- 
sis  could  but  incompletely  eliminate.     These  v.ews, 
he' urges,  are  not  simply  theoretical,  they  are  con- 
firmed by  practice.    In  fact,  blood-letting,  purgatives, 
nitrite  of  amyl,  nitro-glycerin,  etc.,  which    depress 
arterial  tension,  contribute  in  large  measure  to  dimin- 
ish  the  intensity  of  the  attacks.    But  nothing  works 
so  well  as  an  exclusive  milk  diet,  which  acts  marvel- 
ously  in  combating  these  attacks  of  aortic  dyspnoea, 
often  keeping  them  completely  in  abeyance.     Now 
milk  diet,  according  to  Huchard,  acts  m  two  ways 
and  meets  two  indications:   First,  by  the  abundant 
diuresis  which  it  provokes,  the  milk  diminishes  the 
arterial  tension  and  promptly  eliminates  the  toxic 
principles  contained  in  the  blood;  then  it  acts  by  yir- 
tue  of  its  very  harmlessness  and  because  it  does  not 
contribute  to  the  blood  in  circulation,  like  other  ah- 
ments,  and  meat  in  particular,  materials  which,  not 
being  completely  eliminated,  become  rapidly  toxic  to 
the  economy. 


[  toxic 
em  to 
n  of  a 
several 
from  a 
art  and 
y  detri- 

of  his 
ssimilar 

by  the 
)-sclero- 
»  views, 
ire  con- 
rgatives, 

depress 
0  dimin- 
ig  works 

marvel- 
lyspnoea, 
B.     Now 
wo  ways 
abundant 
ishes  the 
:he  toxic 
ts  by  vir- 
does  not 
other  ali- 
rhich,  not 
y  toxic  tO' 


-  6s  _ 

INSOMNIA    OF   GASTRO-INTESTINAL    ORIGIN. 

Writers  have  dwelt  much  on  the  cerebral  hyoer- 
-rn.a  attending  disordered  states  of  the  stom'a'ch 
Ihat   mdigestion   causes  insomnia  by  exciting  the 
cerebrum  is  a  matter  of  common  experience.  Vith 
many  persons,  even,  the  active  exercise  of  digestion 

1  p'  Suet  '"h ''ff '  '^  '"^^""P^^'^'^  ^^^ 
s^ep.     Such  md.viduals  refrain  from  lunching  or  par- 

takmg  of  a  hearty  meal  before  going  to  bed  CerfaTn 
valetudmarians  cannot  drink  a  glasf  of  milk  or  eat  a 
biscuit  late  in  the  evening  without  atoning  for  ^le 
md.scret.on  by  hours  of  sleeplessness 

Such  inhibition  of  the  cerebrum  by  the  stomach 
s  of  frequent  experience  in  the  nursery.     The  fim 
thmg  the  physician  thinks  of  when  consulted  S 
reference  to  insomnia  in  a  young  child  is  the  proTa 
b.htyof  .nd.gest.on  as  the  main  factor' in  the  case 

tkvld  :  '"''?  °'  ^'^  '°°^'  "^^^  ^b-^  the  quan." 
At[;nH  ^  .;'  "^^  '°"^'''°"  °f  '^'  d'«««t've  organs  ? 
Attention  to  these  points,  in  the  absence  of  objective 
s.gns  o  .mportance,  as  fever,  will  generally  pi  one 
on  the  track  of  the  cause  and  suggest  the  remedy 
«nH    .r  *"^'f '*.'°"  ™ay  be  functional  or  organic 

Hkelv  to'bl       ''"'  '°"''"°"^  ''  '"^^  ^^°™-'  are 
likely  to  be  accompan.ed  by  insomnia.    Structural 

diseases,  as  gastritis,  ulcer,  gastrectasis,  cancer.  cauTe 

skeplessness,  both  by  the  pain  and  discomfort  and 

the  consequences  of  indigestion  which  attend  them 


—  66  — 

„rlc«  are  often  formed  by  the  mal-elaborat.on  of 
^poTs;   .Use    irritate   .h.  nervous   centres   and 

n'.t*;::trotre?rpeTof.He<,„^^^^^^^^^^^ 

^r  he  Bushing  of  the  stomach-at  the  expense  of  the 
to  the  fl"s»^'"g  °  necessary  condition  of  its  func- 

ZTme^^no^Z^Zrs  without  attracting 
tion.     Uigesuon  j  ^^^^^^  ^^    ^n 

the  conscousness    and     her     .s       ^^^^^^  ^  ^^^^^^ 

'TLlTrweUas'in  carnivorous  animals.    It  is 
""ot  trueThat  durUig  sleep  the  digestive  functions  are 

:■!  „^,  the  .-rnrr^srr-^'h": 

:r^^nd  in"  X'LinL,  so  accurate  .s 

•  Insomnia  and  its  Therapeutics,  p.  iQ^- 


ion  t» 
ormal 
ed  by 
jmach 
g  the 
Toxic 
ion  of 
s    and 

>n.  In 
arterial 
3  sleep. 
I,  espe- 
ributed 
B  of  the 
ts  func- 
tracting 

why  on 
I  hearty 
is.  It  is 
tions  are 
ive  said: 
;heir  act- 
le  move- 
:,  if  not 

with  an 
curate  as 


-  67  _ 

tiT/r''".'      I^'  ''"""''^  ^"^  '"^^«""««  continue 
he,r  function  dunng  sleep,  though  with  lessened  act- 

ZJr.  '^%*^"«"«"«.^'-«  "ot  suspended,  the  unstriped 
muscular  fibre  continues  a  constant  though  dimin- 
.shed  action;  the  spinal  cord  even  seems  prfternar. 
ally  active  the  inhibiting  restraint  of  the  cerebrum 
being  withdrawn.  In  reality,  in  sleep  all  the  essential 
functions  continue  to  be  exercised.  Those  most 
indispensable  to  life,  circulation,  respiration,  diges 
.on.  etc.,  are  performed  as  during  the  waking  per bd 

fo'Tv  r''  ''T^'^''^-    ^''"'' ''''  ""''''  belts  more 
slowly  during  sleep.     "  J^u/sus  in  somno  parvi  Ian- 

gmd,  ran;'  says  Galen.     With  the  retardafion  ^f  the 
circulation,  there  is  diminished  activity  of  the  secret 
ing  glands  (gastric,  intestinal,  pancreatic,  etc.),  but  in 
healthy  persons  these  organs  are  adequate  to  the  work 
imposed  upon  them,  as  is  proved  by  the  fact  that  mul- 
titudes can  eat  a  full  meal-on  going  to  bed,  sleep 
soundly,  and  be  ready  for  another  meal  on  awak  ng' 
Nor  can  It  be  said  that  the  peristalsis  of  the  gastro 
mtestinal  canal  ceases  during  sleep,  any  more  than 
the  contraction  of  other  unstriped  muscles  (the  arteri- 
oles, for  instance),  which  are  not  under  the  will 

Germain  S^e,  who  refers  most  cases  of  digestive 
insomnia  to  d  fficulties  attending  the  secondaryTr  „! 

lane)   hus  defines  this  kind  of  insomnia:    "Intestinal 
digestion  generally  begins  three  hours  after  a  la 
and  ends  in  seven  or  eight  hours.     The  patient,  we 


_  68  — 

.  ..  f.  o'clock  P.M.    At  10  o'clock  ho 
will  MppoM,  sups  at  '<>>='''';";  (,„  midnight. 

goes  to  l,ed,b„.  77 '7Xl°ic  intestinal  diges- 
r;:::iro:"ertri,«ni.Hca,  the  patient 

-« ;c^t.at .  - 'i- -i'r»;:«  -  ■- 

insomnia,  let  •'•'  P"^'  ^t  /  JcLk  in  the  after- 

ronrdVe':mr<.:hath/wiiuotosi«patt.e 

^-!^r;Ln,en.;n;-ni^^^^^^^^^^^^^ 

irrrtH. --- "'  -  .o^acn.  ^.^- 

tines,  and  the  ^''^^^1°'f'Z^,^y  committed  as  to 
(,)  Errors  are  most  '"^»f"^,  ^e  competent  to 

,„antuy,    -r-'f'f  ^:,rSnrpl  0°  Simculty. 
dispose  of  a  certain  bulk  «''»°  J"        ,h,  stomach; 

while  an  excess  7»«J„^:;X  und"  ""'"°'""'' 
decomposition  and  ««nl=nce  se  .^ 

microblc  rule-,  pntrid  ""^  J"'  "  ..bilious"  condi- 

,nd  ptomaines  are  f-""','''".  has  experienced  a. 
tion  supervenes,  such  js  every  o  ^^^^  „^ 

times.    "  is ''"""''^""ttrtd  by  excessive  eat- 

?;trCa:^nr  Cm^^. -^^^^^^^ 

i^ri:rbSS  strHiU  ^not  let  the 

brain  rest. 

— ■       ,,r     Second  edition.    Paris,  1883. 

•  Des  Dyspepsjes,  etc.    seconu 


sas***''-^*" 


A  , 


ck  he 
night, 
diges- 
latient 

of  the 
at  the 

after- 

at  the 

jestion, 
*  taken 
I,  intes- 

:d  as  to 
letent  to 
ifficulty, 
itomach; 
molested 
:ic  gases 
"  condi- 
ienced  at 
udes  are 
ssive  eat- 
lly  comes 
and  over- 
3t  let  the 

rl»,  1883. 


-  69  ~ 

The  proper  remedy  for  sleeplessness  arising  from 
this  cause  is  apparent;  it  is  to  curtail  the  daily  rations 
to  the  physiological  standard.  The  necessity  of  eat- 
ing  slowly  and  deliberately  with  thorough  mastication 
of  the  food,  IS  apparent;  those  that  "  bolt  "  their  food 
are  sure  to  eat  to  excess. 

(2)  Food  of  poor  or  insufficient  quality  produces 
anaemia  and  starvation  of  vital  organs,  including  the 
cerebrum,  and  hence  engenders  insomnia.   Physicians 
cannot  too  much  insist  on  the  necessity  of  a  full  diet 
that  IS,  of  an  adequate  admixture  in  the  daily  fare  of 
albuminoids,  fats,  and  carbo-hydrates.     Food  of  in- 
digestible  quality  produces  essentially  the  same  evils 
as  excessive  alimentation.     Under  this  head  may  be 
included   food    improperly  or    insufficiently  cooked 
(good  cookery  under  our  civilization  has  become  in- 
dispensable to    healthy  digestion),   and   foods  that 
most  persons  of  sedentary  habits  find  hard  to  digest 
as  unripe  fruit,  pastries,  hot  bread,  fried  pork,  confec- 
tionery. Of  course,  butcher's  meats  should  be  selected 
that  are  tender  and  juicy,  and  in  the  light  of  recent 
discoveries   (Gautier,   Selmi,   etc.),   it  is  doubtful   if 
meat  or  game  that  has  become  high  {faisandd)  is  fit 
tor  food. 

Foods  of  themselves  sufficiently  digestible  may 
become  indigestible  if  too  many  kinds  are  eaten  at  a 
meal.  But  this  brings  us  again  to  the  evils  of  excess- 
ive  eating. 

It  need  not  be  repeated  that  he  who  would  sleep 


■/ 


—  70  — 
well  must  avoid  those  articles  of  diet  which  have  been 
found  to  be  indigestible,  or  should  indulge  .n  them 
sparingly.    Much  depends,  of  course,  on  the  muscular 
work  done.    Horace  speaks  of  the  Jura  ilia  me^sorum 
The  hay-makers  on  the  salt  marshes  need  food  hard 
of  digestion,  that  is,  food  that  is  :r/tw/y  digested,  yield- 
ing  up  force  for  many  hours;  food  that  m  common   . 
parlance  "stays  by,"  such  as  baked  beans  and  pork» 
boiled  beef  and  cabbage,  and  mince  p>e.     Such  per- 
sons sleep  well,  despite  their  hearty  fare;  it  is  especi- 
ally the  "brain-workers,"  the  men  of  sedentary  habits^ 
that  are  upset  by  a  rich  diet.  • 

(i)  A  healthy  digestion  presupposes  a  healthy 
state  of  the  stomach,  intestines,  and  accessory  organs, 
and  any  derangement  of  these  viscera  must  be  cor- 
rected by  suitable  medicinal  and  dietetic  means  before 
normal  sleep  can  be  enjoyed. 

To  enter  on  a  consideration  of  all  these  derange- 
ments would  take  more  space  than  we  have  at  our 
command.  The  hygienic  treatment  of  indigestion  in- 
cludes dieting,  exercise,  recreation,  cold  bathing  etc. 
The  cold  shower-bath  in  the  morning  is  sometimes  a 
powerful  aid  to  digestion.  Exercise  promotes  a  more 
vigorous  circulation  and  favors  peristalsis  and  chymi- 
fication;  equally  necessary  are  change  of  *cene,  diver- 
sions, and  the  cultivation  of  a  contented,  cheerful 

frame  of  mind. 

Among  the  medicinal  means  are: 

(i)  Such  as  favor  gastric  digestion,  namely,  alka- 


—  71  — 

Ohi.'^f'"'   '"'"'\""'    '''''^'    ^'"^    I'^'l'-".    after, 
value.     Small  doses  of  strychnine  are  u.seful 

(a)  For  ac.c!(iyspei).sia  full  doses  of  bicarbonate 
of  soda  are  naturally  ind.cated.      Profe.ssor  S6e  ad 
V.  es  dyspepfcs  with  excess  of  acid  secretion  to  take 
a  drachm  of  b.carbonate  of  .soda  in  hot  water  on  go 
.ng  to  bed.     It  .s  certain  that  in  certain  morbid  states 
of   he  stomach  and  intestines,  whether  due  to  "  A^ 

s  da^if ';    r  .'V'''  "^  '""-«'  ^he  beneficial 
sedative  effects  of  alkalies  are  pronounced. 

(3)  Constipation  is  another  recognized  cause  of 
insomnia,  whether  by  the  reflex  irritatfon  of  re  ai  ,ed 

TZTco/  ^''^^^^"'--  -^-^  f-q-ntiy  attrd 
a  loaded  colon.  Here  the  remedy  is  obvious;  such 
laxatives  as  rhubarb,  Glauber  salts,' cascara.  enema  a 
of  hot  water,  etc.  Persons  who  sleep  poorly  from 
th.s  cause  often  find  a  hot  water  enema  on  going  to 
bed  a  sovereign  remedy.  ^ 

fif  th?'"  T^^"^  ^"«^*''"'"'  *  ^°^P'd  "^«'-.  '«  at  fault 
(.f  this  can  be  determined),  of  course  a  blue  pill    a 

dicLl'"""^™*"  "'  P^^^P'^y"'"  *«"'d  seem  to  be'in 

There  is  an  acidity  of  the  stomach  which  depends 

smo'n  ofT'  f '  '""^"^^'  ''^  P^"'^-'^  °^  ^-oCo- 
s.t.on  of  starches  or  sugars  in  the  food.      In  these 

cases,  washing  out  the  stomach  by  means  of  emet!;I 

and  copious  draughts  of  warm  water  every  nigrtfor 

three  or  four  nights,   as   Macfarlane    recommends 


•"  ' :"  _  7«  — 

often  proves  very  efficacious.  The  same  writer  ad- 
vises ferro-alumen  in  three-grain  doses  for  pyrosis 
along  with  three  drops  of  dilute  hydrocyanic  acid,  and 
turpentine  in  ten-drop  doses  for  flatulence,  as  most 

effective  remedies.  j       „ 

Gastralgia  and  gastrodynia   demand   anodynes 
and  anti-spasmodics.     In  the  experience    of    many 
authorities,  a  pill  of  opium,  or  an  equivalent  of  the 
deodorized  tincture  is  more  efficient  in  gastralgia. 
than  morphine  hypodermically  or  by  mouth. 

In  the  treatment  of  gastric  neurasthenia,  the  fol- 
lowing therapeutic  regulations  may  be  carried  out : 

1    The  patient  may  take  with  each  meal  s  grains 
each  of  salicylate  of  bismuth,  magnesia,  and  bicarbon- 

ate  of  sodium.  ,      „,» 

2.  He  may  take,  on  going  to  bed,  a  dessert- 
spoonful of  compound  licorice  powder. 

3  Every  day  he  may  have  a  cold  jet-douche  of 
IS  seconds'  duration  applied  along  the  vertebral  col- 
umn; energetic  dry  friction  with  a  flesh-brush  after 

the  douche. 

4  Walks  in  the  open  air,  muscular  exercises 
(fencing,  opposition  gymnastics,  etc.,)  are  beneficial 

'  5  There  should  be  only  two  meals  a  day,  the 
one  at  lo  a.m.  and  the  other  at  7  p-m.  The  diet 
should  consist  chiefly  of  eggs,  cereals,  green  veget- 
ables and  fruits;  the  eggs  to  be  nearly  raw,  the 
starchy  foods  and  vegetables  to  be  thoroughly 
cooked,  the  fruits  to  be  stewed.     Drinks  to  be  water 


'•^^, 


ter  ad- 
pyrosis 
;id,  and 
■s  most 

lodyncs 
many 
of  the 
stralgia , 

the  fol- 

out: 

5  grains 
icarbon- 

dessert- 

)uche  of 
ibral  col- 
ish  after 

exercises 
ineficial. 

day,  the 
The  diet 
en  veget- 

raw,  the 
loroughly 
i  be  water 


—  73  — 
or  a  light  white  wine  with  ordinary  water;  no  gaseous 
waters,  no  pure  wine,  no  whiskey  or  other  distilled 
hquors.     Such  patients  often  do  best  on  a  dry  diet* 

Intestinal  indigestion  is  to  be  treated  mainly  by 
<lteting.  The  liquor  pancreaticus  has  been  recom- 
mended by  some  writers;  it  is  doubtful  if  pancreatin 
exercises  any  action  outside  of  the  stomach.  Diar- 
rhoea and  constipation  are  to  be  treated  by  the  appro- 
priate remedies. 

Sleep,  in  this  form  of  indigestion,  is  often  im- 
proved by  the  nightly  use  of  massage,  and  also  by  the 
application  of  a  bag  of  hot  water  over  the  abdomen 
(Macfarlane). 

THE   INSOMNIA    OF   CYSTITIS. 

Chronic  cystitis  produces  obstinate  and  painful 
insomnia.  This  disease  is  a  common  consequence  of 
enlarged  prostate,  calculus  in  the  bladder,  of  gonor- 
rhoea, and  stricture  of  the  urethra.  Micturition  is 
frequent,  and  attended  with  scalding  pain;  the  urine 
contains  muco-pus,  which  adheres  to  the  bottom  of 
the  vessel  when  turned  upside  down. 

Sleep  is  interfered  with  both  by  the  pain  (which 
in  chronic  cases  may,  however,  be  absent)  and  by  the 
frequent  calls  to  urinate.  The  victim  of  cystitis  and 
prostatitis  is  obliged  to   get  up   every  hour  or  two 

*Dujardin-Beaumetz,  Therapeutic  Gazette,  January 
15th,  1890.  ^  ' 


—  74  — 
(sometimes  every  half  hour)   in  the  night  to  make- 
water,  and  the  act  of  micturition  is  often  attended 
with  a  tenesmus  that  is  most  distressing. 

The  treatment  should  aim    at  removal  of    the 
cause.     If  there  is  a  stricture  or  enlarged  prostate  or 
stone  in  the  bladder,  the  proper  measures  should  be 
taken  for  their  removal  or  relief.    If  the  cause  can- 
not be  reached,  recourse  must  be  had  to  palliative 
remedies.     Washing  out  the  bladder  every  day,  or 
twice  a  day,  with  warm  water,  to  which  some  antisep- 
tic is  added,  as  Marchand's  peroxide  of  hydrogen, 
carbolic  acid,  boric  acid,  thymol,  is  now  recommended 
by  the  best  authorities,  and    certainly  often    gives- 
marked  relief.     I  have  known  patients,  who  had  been 
long  sufferers  from  prostatic  disease  which    made 
their  nights  wearisome  and  life  a  burden,  able  io 
obtain  several  hours  of  quiet  sleep  after  irrigating  the 
bladder  with  a  little  warm  carbolic  water.     For  this 
purpose    the  soft    rubber    catheter    is  very  useful. 
These  are  of  various  makes.     The  Jacques  French 
catheter,  the  Tiedmann,  the  Davidson,  are  those  with 
which  I  am  best  acquainted.    The  peculiar  merit  of 
these  ■    ,  -uments  is  that  they  may  safely  be  left  to 
the  pauc.a  to  be  pass  ed  by  himself.     The  catheter  is- 
first  greased  with  a -little  eucalyptrs  vaseline    and 
passed  into  the  urethra,  then  carefully  pushed  along 
till  the  flow  of  urine  by  the  distal  end  indicates  that 
it  is  in  the  bladder.     After  emptying  the  bladder,  the 
cannula  of  a  little  hand-ball  syringe,  which  is  filled 


■■  ^^^^<'WW4TM((ttaBglii.-ufci ; 


■^.e*aia»»>i»w|^,iiM^i  r,fmpi)amimiti-sttiij:^-„ 


make- 
ended 

f  the 
ate  or 
lid  be 
e  can- 
liative 
ay,  or 
titisep- 
rogen, 
lended 

gives 
d  been 

made 
,ble  io 
ing  the 
or  this 
useful. 
French 
se  with 
lerit  of 

left  to 
[leter  is- 
ne  and 
i  aloMg 
tes  that 
der,  the 
is  filled 


—  75  — 
with  the  antiseptic  solution,  is  introduced  into  the 
mouth  of  the  catheter  and  the  contents  injected  into 
the  bladder;  the  solution  is  then  allowed  to  run  out, 
and  more  is  injected  till  the  water  flows  off  clean  and 
free  from  mucus. 

Too  much  pains  cannot  be  taken  to  have  the 
catheter  always  clean  and  aseptic;  obstinate  cystitis 
has  been  more  than  once  started  by  the  use  of  a  foul 
catheter. 

Suppositories  of  morphia,  of  opium,  of  hyoscya- 
mus,  etc.,  are  often  advantageous.  The  following 
prescription  is  frequently  employed  in  the  Jefferson 
Medical  College  Hospital  of  Philadelphia: 

5     Pulv.  opii gr.  xij. 

Camphorae gr.  xxx. 

Ext.  belladonna gr.  iij. 

Cacao q.  s. 

M.  et  in  suppos.  No.  vi,  divide. 
S.     One  each  night  on  retiring. 

A  teaspoonful  of  the  tincture  of  hyoscyamus  at 
bedtime  sometimes  proves  to  be  a  useful  hypnotic  in 
cystitis.  The  ordinary  hypnotics  (chloral,  sulphonal, 
paraldehyd,  urethan)  are  of  little  or  no  benefit. 

INSOMNIA    FROM  GENITAL  IRRITATION. 

In  this  connection  it  is  necessary  to  allude 
to  the  insomnia  which  attends  genital  irrittLion. 
While  excess  in  venery  sometimes  causes  insomnia  by 
impairing  nervous  tone,   there   is    another  frequent 


.   -  76  - 

cause  in  individuals  otherwise  healthy,  viz.,  contin- 
ence. Every  physician  is  now  and  then  consulted  by 
vigorous  young  men  who  have  at  some  time  given 
loose  reins  to  their  passions,  and  who  afterwards  m 
consequence  of  prolonged  continence  have  trouble- 
some erections  at  night  which  waken  them  and  keep 
them  awake.  In  such  cases,  in  the  event  of  the 
physiological  satisfaction  of  an  imperative  want  bemg 
impracticable,  recourse  must  be  had  to  sedative  medi- 
cines, to  anaphrodisiacs. 

The  suppository  of  camphor  and  opium  (see 
above)  may  be  given  to  advantage,  or  a  full  dose  of 
chloral,  or  of  bromide,  has  a  great  reputation  in  in- 
somnia due  to  genital  irritation.  It  should  be  given 
in  large  doses  and  followed  up  for  some  time. 

5     Pot.  bromide 5  '^• 

Tinct.  hyoscyatni 5  ss. 

Mist  camph 5  v*^- 

M.    Sig.     A  tablespoonful  three  times  a  day  and  at 

bed  time. 

Lupulin,  which  may  be  given  in  drachm  doses 
stirred  into  a  small  cup  of  hot  water  at  bedtime,  is  of 
ancient  repute,  and  the  same  may  be  said  of  full  doses 

of  camphor. 

Not  much  can  be  said  in  favor  of  cold  douches 
to  the  perineum,  which  would  be  likely  to  aggravate 

the  trouble. 

The  patient  should  sleep  on  a  hard  mattress,  not 
on  feathers,  and  should  accustom  himself  to  sleep  with 
very  few  bedclothes  over  him. 


.-*'^i»tu. 


;ontm- 
ted  by 
given 
rds  in 
ouble- 
1  keep 
of  the 
t  being 
:  medi- 

m   (see 

lose  of 

in  in- 

;  given 


r  and  at 

m  doses 
le,  is  of 
[11  doses 

douches 
rgravate 

■ess,  not 
eep  with 


—  77  — 
The  utility  of  avoiding  romances  of  a  certain 
character  as  well  as  everything  else  that  can  stimu- 
late the  sexual  passion  (and  under  this  head  come 
tobacc3  and  alcohol)  is  sufficiently  obvious. 

INSOMNIA    OF    TOXIC    ORIGIN. 

The  natural  effect  of  alcohol  on  the  cerebral 
functions  is  to  impair  healthful  sleep.  It  excites  the 
cerebrum  by  increasing  the  heart's  action  and  the 
blood-flow,  and  by  directly  stimulating  the  cortical 
cells  concerned  in  conscious  activity.  This  is  the 
ordinary  action  of  alcohol  when  taken  moderately, 
the  effects  of  liquors  being,  as  a  rule,  the  less  baneful 
the  less  impurities  they  contain,  and  the  nearer  they 
approach  by  rectification  or  by  age  to  the  type  of 
pure  ethyl  alcohol. 

It  is  possible  that  the  stimulant  effect  of  the  alco- 
hol on  the  stomach,  rendering  that  organ  hyperaemic, 
may  sometimes  promote  sleep  by  temporarily  ansemi- 
ating  the  brain.  On  the  whole,  however,  alcohol  is  a 
most  unsatisfactory  hypnotic,  and  the  sleep  which 
attends  its  ingestion  is  generally  brief,  and  followed 
by  a  period  of  wakefulness  later  on. 

It  is  by  no  means  proved  that  alcohol  in  any 
form  ever  fulfils  the  prime  requisite  of  a  hypnotic, 
that  of  lessening  the  amount  of  blood  in  the  brain! 
The  stupor  which  follows  smaU  medicinal  doses  is 
regarded  by  many  authorities  as  a  minor  degree  of 
that  narcosis  which  comes  on  after  excess.     Into  this 


_  78  - 
narcotism  enter  as  factors  the  toxic  effects  of  the 
alcohol  on  the  cerebrum,  vasomotor  paresis,  and  tae 
paralyzing  action  of  blood  poisoned  by  carbonic  acid, 
whose  retention  is  due  to  interference  with  the  respi- 
ratory function.     Jaillet,  moreover,  has  shown  that 
the  blood  globule,  when  impregnated  with  alcohol, 
loses  the  property  of  transforming  all  its  hemoglobin 
into  oxyhemoglobin;  for  the  oxygen  of  respiration 
unites  at  the  same  time  with  the  alcohol  and  the 
hemoglobin  of  the  corpuscles;  in  other  words,  the 
alcoholized  blood  becomes  too  poor  in  oxygen  to  pro- 
perly subserve  either  the  nutrition  or  function  of  the 
cerebral  cells.     These  considerations  show  how  com- 
plex is  the  action  of  alcohol  on  the  brain,  and  the 
necessity  of  caution  in  prescribing  it  in  derangements 
of  sleep.    Certainly  the  continued  use  of  alcoholic 
stimulants,  even  in   moderate  doses,    for    hypnotic 
effect,  is  likely  to  defeat  the  purpose  for  which  the 
remedy  is  given,  by  producing  in  the  end  a  very  ob- 
stinate insomnia,  if  we  can  trust  some  recent  authori- 
ties- and  this  it  does  by  inducing  a  permanent  loss  of 
tone  in  the  cerebral  blood-vessels,  if  not  by  favoring 
arteriosclerosis.      "The    effect  of    alcohol  on    the 
brain  "  says   B.  W.  Richardson,  "  is  to  produce  and 
maintain  the  relaxation  of  its  vessels,  to  keep  them 
chafed  with  blood,  and  so  hold  back  the  natural 
repose      Under  thi^ divergence  from  natural  life,  the 
sleepless  man  lies  struggling  with  unruly  and  uncon- 
nected trains  of  thought.     .     .    .    The  more  he  tries. 


i«w«ite**««s*«K^ '■- 


of  the 
nd  fae 
ic  acid, 
respi- 
n  that 
ilcohol, 
jglobin 
jiration 
ind  the 
•ds,  the 
to  pro- 
of the 
>w  com- 
and  the 
gements 
ilcoholic 
lypnotic 
dich  the 
very  ob- 
authori- 
it  loss  of 
favoring 
on    the 
luce  and 
ep  them 
5  natural 
1  life,  the 
id  uncon- 
■  he  tries, 


—  79  — 
the  less  he  succeeds,  till  the  morning  dawns  "    Rich 
ardson  affirms  that  arterial  atheroma  is  a"  frequent 
consequence  of  even  moderate  indulgence  in  alcoholic 
beverages  and  doubtless  there  is  much  testimony  in 
support  of  this  contention.    As  for  the  effects  of  Ion? 
contmued  mtemperance,  there  is  no  doubt  that  this  is 
one  of  the  most  prolific  sources  of  arterial  degenera- 
tion. Nor  .s  even  beer  exempt  from  harm  of  the  same 
kmd,  and  there  is  warrant  for  the  belief  that  "the  use  of 
beer  m  many  instances  produces  a  species  of  degener- 
ation of  a^l  the  organs,  profound  and  deceptive  fatty 
deposits,  diminished  circulation,  conditions  of  conges- 
tion and  perversion  of  functional  activities;  local  in- 
flammations of  both  liver  and  kidneys  are  always 
present  ••    Intellectually,  a  stupor  amounting  almos 
to  paralysis  arrests  the  reason,  changing  all  the  higher 
faculties  into  a  mere  animalism,  sensual,  selfish,  slug- 
gish, varied  only  with  paroxysms  of  anger  that  are 
senseless  and  brutal.    A  writer  in  the  Scientific  Amer- 
ican, who  makes  this  assertion,  claims  a  wide  observa- 
tion of  the  effects  of  beer-drinking  among  the  various 
•civilized  nations,  vauuus 

U  fh^^lu^^  ^f"'  '"'''"''  """  *''*^  ^^'^  t°  emphasize 
«s,  that  the  moderate  use  of  alcohol  in  any  form  may 

produce  insomnia  by  its  exciting  action  on  the  heart 

and  circulation,  and  on  the  cerebral  cells;  that  the  use 

r.  H  f  ^'  ^^yP"°''"  '"^y-  *»  the  long  run,  defeat  the 
end  for  which  it  is  given;  and  that  prolonged,  immod- 
erate indulgence,  even  in  the  milder  intoxicant  bever- 


,,,.^;:>:       _  80  — 

ages,  may  produce  grave  cerebral  disturbances  and 
such  as  are  incompatible  with  healthful  sleep. 

The  remedy  for  alcoholic  insomnia  is  that  ot  ai- 
coholism  in  general-the  most  complete  abstinence 
from  the  toxic  cause.     Prolonged  mental  rest,  the 
natural  vaso-motor  tonics,  out-door  air,  massage,  in- 
vigorating  exercise,  cold  bathing,  and  perhaps  sea- 
bathing, are  indicated,  and  a  nutritious  diet  adapted 
to  the  enfeebled  state  of  the  digestive  organs.    These 
patients  are  often  benefited  by  a  prolonged  course  of 
strychnia.     One-thirtieth  of  a  grain  may  be  given 
three  times  a  day,  or  ten  drops  tincture  of  nux  voni- 
ica,  just  before  meals.     Hypnotics  will  be  temporarily 
needed-chloral  or  paraldehyd.     The  combination  of 
twenty  grains  of  chloral  with  twenty  drops  of  tincture 
of  capsicum,  in  two  fluid  ounces  of  chloroform  water. 

is  a  good  one. 

Physicians  are  seldom  called  upon  to  treat  insom- 
nia due  to  tea-drinking  or  coffee-drinking.    The  num- 
ber of  those  who  abuse  these  beverages  is  probably 
.mall,  and  the  congenitally  feeble  and  neuropathic 
early  learn  by  experience  to  indulge  sparingly   in 
them     The  tea-drinking  malady  is  characterized  by 
»  sleeplessness,  or  sleep  disturbed  by  dreams  or  night- 
mare,  headache,  irritability  of  temper,  depression, 
hypochondriasis,  disorders  of  special  senses,  auditory 
and  visual  disturbances,  neurosal  palpitation,  dyspep- 
sia, intestinal  torpor  (with  the  accompanying  flatu- 
lence  and  constipation),  neuralgia,  muscular  enfeeble- 
ment  and  tremor."     (Macfarlane.) 


s  and 

of  al- 
inence 
it,  the 
ge,  in- 
)s  sea- 
dapted 
These 
urse  of 
given 
X  vom- 
)orarily 
ition  of 
tincture 
1  water, 

t  insom- 
le  num- 
>robably 
ropathic 
ingly  in 
rized  by 
)r  night- 
pression, 
auditory 
dyspep- 
ng  flatu- 
enfeeble- 


—  8i  _ 

^^     Insomnia  is  a  frequent  consequence  of  excesses 
m  the  use  of  tobacco.     This  is  brought  about,  partly 
by  the  digestive  and  circulatory  troubles  which  char- 
acterize  chronic  nicotinism. 

But  the  nervous  centres  are  most  violently  smit- 
ten, especially  the  medulla  oblongata,  whence  the  car- 
diac,  circulatory,  and  respiratory  disturbances.  The 
direct  excitant  influence  of  nicotine  on  the  cortical 
.  centres  IS  considerable;  the  existence  of  vaso-motor 
paresis  is  undoubted. 

Entire  abstinence  is  the  only  remedy;  the  poison 
«s  quickly  eliminated.  It  has  been  found  that  the 
wakefulness  is  lessened  by  four-gramme  doses  of 
monobrom.de  of  camphor  at  night  (Macfarlane),  but 
any  of  the  milder  hypnotics  may  be  administered 

The  only  other  toxic  agent  necessary  to  allude  to 
IS  opium.     Opium  and  morphine  may  almost  be  said 
not  to  deserve  a  place  among  true  hypnotics,  so  little 
do  they  bring  about  the  conditions  of  normal  sleep 
It  IS  known  that  they  render  the  cerebrum  hyper^mic- 
they  paralyze   the  vaso-motors,  and   act  upon  the 
nerves  which  supply  the  respiratory  muscles  so  as  to 
interfere  with  the  process  of  respiration  (W  A  Ham- 
mond); hence  the  sleep  which  results  from  their  use 
is  more  like  stupor  than  natural  sleep 

attenir''  *?^'''"^^^  *"''  unmanageable  insomnia 
attends  the  opium  or  morphine  habit,  for  the  cure  of 
which  special  treatment  is  necessary  (especially  in 
aggravated  cases),  and,  generally,  isolation  in  an  insti- 


_    82    — 

tution   possessed    of    properly    trained    nurses,  and 
where  restraint  can  be  exercised. 

The  literature  of  morphinism  is  now  quite  exten- 
sive; prominent  among  worics  devoted  to  this  subject     . 
are  two  treatises  lately  published,  one  by  Regnier,  the 
other  by  Oscar  Jennings.  .        ,    , 

In  breaking  off  the  habit,  Jennmgs  declares  in 
favor  of  the  gradual  method;  and  in  conjunction  with 
Professor  Ball  he  has  made  some  careful  experiments 
on  the  power  of  sparteine  and  nitro-glycerin  to  com- 
bat the  circulatory  disturbances  which  attend  the 
period  of  amorphinism. 

INSOMNIA    OK     CONTINUED     FEVERS     AND    ITS    TREAT- 

MENT. 

In  typhus  and  typhoid  fever,  sleeplessness  is  a 
frequent,  troublesome,  and  often  dangerous  symptom. 
Dr  Murchison,  writing  of  the  necessity  of  sleep  m 
tvDhus  says:  "The  practitioner  cannot  be  too  forci- 
bly  impressed  with  the  fact  that  loss  of  sleep  at  any 
stage  of  typhus,  if  it  continue  for  two  or  three  nights, 
is  of  itself  sufficient  to  kill."  . 

In  typhoid  the  necessity  of  sleep  is  no  less  ur- 
aent  One  of  the  first  symptoms  of  approaching  dis- 
soluiion  is  a  restlessness  which  forbids  sleep,  and  the 
return  of  refreshing  sleep  is  hailed  by  physicians  and 
attendants  as  a  presage  of  recovery. 

In  the  earlier  stages  of  these  fevers,  insomnia    s 
pretty  certain  to  accompany  the  hyperthermia,  while 


f. 


3 


,   and 

;\len- 
ubject 
it,  the 

ires  in 
n  with 
iments 
0  com- 
id  the 

rREAT- 

ss  is  a 
mptom. 
ileep  in 
10  forci- 
)  at  any 
!  nights, 

less  ur- 
ling  dis- 

and  the 
ians  and 

amnia  is 
lia,  while 


-  83  _ 

sleep  often   attends  a  fall   in   the  temperature     It 

would  seem  that  over-heated  blood  is  itself   inimical 

o  sleep  by  excitin,  the  cerebrum.     Certain  it  IZ^ 

disturbances  and  promote  sleep.     Hence,  for  the  rest- 
essness  and  msomnia  of  typhus  and  typhoid  feve 
there  .s  often  no  better  treatment  than  a  cold  bath  o/ 
about     fteen  minutes-  duration,  the  tem? lure  o 
th     water  being  from  60°  to  75^  F.,  and  during  the 
bath  cold  water  may  be  poured  on  the  head  in  case! 

wh!iefif:;e.r"^'^ "''  "^^'^^^"«««  -^  ^«"'i- 

r  the  fehrT".  "  °"^^'  ^°  '^  '°"^  ^"°"K''  '°  de- 
cases  ^hVi:  '  "'  u  "'"'^  ''''  "°^'"«''  '"  ^ome 
cases  the  bath  may  be  of  longer  duration.     "The 

earher  the  stage,   the  higher  the  fever,   the   more 
robust  the  constitution,  the  colder  should  the  ^at 
be.     The  later  the  stage,  the  weaker  the  constitution 

.nH  f^""^  7"'^?  '''^''"  '°  ^*^«  f°""d  cold  sponging 

bath  oThlrH  %"'^'""^  ^"'^^'^"^«  ^-  'h«  -  d 
bath  Others  havp  derived  only  a  temporary  refresh- 
mg  from  these  milder  means.  -^X  reiresh- 

Where  the  cold  bath  is  impracticable,  from  diffi 
cuUies  on  the  part  of  the  patient  or  his  su'rround.ngs" 
.^me^f  the  new  antipyretics  may  be  tried.  There 

*J.  C.  Wilson. 


i 


._  84  -  , 

is  much  lesfM-iony  in  favor  of  acetanilid  as  a  ncrvou^ 
sedative  in  fevers.  Fivegrainseveryhourforth.ee 
or  fo^r  doses  (in  an  adult)  will  generally  lo.er  the 
febrile  temperature  two  or  three  degrees,  and  one 
o  two  hours  of  quiet  sleep  (..pecially  «f /he  med.dne 
b.  given  in  the  night-time)  is  almost  certa.n  to  follow. 
TK-nany  practitioners  an-'  hospital  phys.c.ans,  anal- 
gLin  is  regarded  as  the  preferable  hypnotic;  the  dose 
should  be  double  that  of  acetanilid. 

These    antipyretics,   though    they    undoubtedly 
have   a  marked  action    on  the  the^.-nogenetic   and 
thermotaxic  heat-centres.  which  are  under  abnormal 
irritation  by  the  fever-poison,  an  action  which  is  ex- 
.vu'cd  to  the  hi,-.,  r  cerebral  centres, certainly  do  no 
aft..tthe  infectiou'   agent,  and  hence  the  course  of 
the  fever  is  not  influenced  by  them.     Their  prolonged 
use  is  probably  attended  by  some  cardiac  depression 
?an  e.\\  to  be  especially  shunned  in  fevers),  and  the 
best  clinical  authorities  are  shy  of  them,  seemg  no 
permanent  advantage   in  the  continued  admrnistra- 
tion  of  these  medicaments,  but  possibly  mischief     At 
he  most  th'.ir  employment  is  restricted  to  the  obten- 
t!:.n  of  s'ch  sedation  L  is  needed  for  the  nervous  dis- 

'"''' Among  the  pure  hypnotics,  chloral  still  des..  vedly 
takes  the  lead  in  the  treatment  of  the  insomnia  of 
\^ll  It  calms  the  delirium,  saves  the  forces  mod- 
erates the  fever,  and  produces  a  sleep  ^-^J^ 
natural    sleep    in    its    refreshing  effects  (l.iebre.ch, 


i 


._J 


^%, 


«>, 


^!^^^o. 


IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


i^j^ 


"/a 


^/ 


1.0 


1.1 


l^y^S    |25 
y.  1^   |2.2 

Ktuu 


|l.25  II . .4    ,,.6 

.4 6"     

► 

Photographic 

Sciences 

Corporation 


\ 


SJ 


<^ 


23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  145S0 

(716)872-4503 


»■ 


CIHM/ICMH 

Microfiche 

Series. 


CIHIVl/ICIN/IH 
Collection  de 
microfiches. 


Canadian  Institute  for  Historical  Microreproductions  /  lnstit?it  Canadian  de  microreproductions  historiques 


<s^' 


_  8s  - 

Nothnagel,  Flint,  Russell,  Dujardin-Beaumetz).  The 
only  contra-indication  is  cardiac  weakness.  In  the 
latter  stages  of  typhus  and  typhoid  it  is  better  to 
avoid  chloral,  substituting  opium  or  morphine,  and  in 
the  earlier  stages,  where  there  is  much  jactitation  and 
delirium,  and  especially  when  diarrhoea  is  a  prominent 
symptom,  20  drops  at  bedtime  of  the  deodorized  tinc- 
ture of  opium  in  a  little  camphor-water  is  a  useful 
adjunct  to  other  measures  intended  to  subdue  rest- 
lessness and  produce  sleep. 

With  regard  to  sulphonal,  we  think  that  experi- 
ence has  proved  this  hypnotic  to  be  of  little  utility  in 
the  obstinate  insomnia  of  fevers,  and  the  same  may 
be  said  of  chloralamid  and  other  of  the  more  recent 
hypnotics.  Paraldehyd,  were  the  taste  not  so  ob- 
jectionable, might  render  considerable  service  in  the 
delirious  insomnia  of  typhus. 

Alcoholic  stimulants  judiciously  administered 
sustain  the  heart  and  circulation,  promote  the  nutri- 
tion and  restoration  of  the  nervous  system,  and  thus 
come  under  the  head  of  remedies  useful  to  combat 
insomnia.  Given  in  too  large  or  too  frequent  doses, 
they  undoubtedly  defeat  the  end  for  which  they  are 
given,  and  aggravate  existing  nervous  dis«^-  bances. 
There  is  another  reservation, — they  must  be  cautiously 
prescribed  where  there  is  renal  insufficiency. 

Stokfs,  in  his  lectures,  speaks  of  the  well-marked 
calming  and  sedative  effect  of  wine  in  fever.  "  A  pa- 
tient who  has  been  restless,  sleepless,  and  delirious 


—  86  — 

will  sometimes  become  quiet  and  fall  asleep  after  the 
administration  of  a  little  wine.  This  occurs  where 
the  nervous  symptoms  are  probably  due  to  an  antemic 
or  spaniemic  condition  of  the  brain  associated  with  a 
weak  heart  and  a  flagging  circulation."* 

Febrile  insomnia  is  essentially  a  toxic  insomnia; 
this  has  been  made  apparent  by  the  investigations  of 
the  last  few  years.    Whether  it  be  the  microbes  or 
their  ptomaines,  or  both,  which  excite  the  cerebrum 
and  derange  the  nervous  functions,  has  not  been  yet 
positively  determined.     Uraemia  probably  enters  as 
an  important  factor;  in  the  active  stages  of  fevers, 
and  in  the  declining  stages  when  the  circulation   is 
oppressed  and  languid,  and  the  prognosis  is  grave, 
elimination    by    the    kidneys    is    always    imperfect. 
Hence  an  important  part  of  the  treatment  should  be 
to  promote  the  excretion  of  the  poison  and  the  re- 
moval of  effete  matters.     Unfortunately,  this  indica- 
tion can  be  but  imperfectly  met.     All  that  can  be 
done  is  by  suitable  nutrients  and  stimulants  to  sustain 
the  organic  forces  in  their  struggle  with  the  foe,  and 
to  favor  elimination  by  the  kidneys  and  other  emunc- 
tories.    The  various  diluents  (lemonade,  barley-water, 
effervescent  drinks,  plain  water,  etc.)  which  are  so 
freely  given,  because  so  constantly  craved,  promote 
excretion  by  the  kidneys.     Milk  is  often  prescribed 
«</ //^//ww  as  the  sole  drink  and  nourishment;  its  di- 


*  "Lectures  on  Fever,"  Lea  Brothers  &  Co.,  1876. 


^»i*<ilKi.»ft^  n<iitiyftj'3*«-o 


;r  the 
ivhere 
iiemic 
nth  a 

mnia; 
ms  of 
)es  or 
sbrum 
;n  yet 
ers  as 
Fevers, 
ion   is 
grave, 
erfect. 
nld  be 
he  re- 
indica- 
:an  be 
sustain 
e,  and 
jmunc- 
-water, 
are  so 
romote 
iscribed 
its  di- 

'6. 


-  87  - 

uretic  properties  are  well  known.  Some  clinical 
authorities  are  in  the  habit  of  ordering  mild  diuretic 
mixtures  (solutions  of  nitrate  of  potassium,  of  sweet 
spirits  of  nitre,  with  sometimes  the  addition  for 
several  successive  days  of  a  little  digitalis)  all  through 
the  fever,  and  claim  good  results. 

The  bowels  should  be  kept  open,  suitable  mild 
laxatives  being  given  if  there  be  constipation,  and  fre- 
quent cold  or  tepid  ablutions,  followed  by  brisk  rub- 
bing, will  do  something  towards  promoting  the  func- 
tions of  the  skin. 

We  have  hinted  at  anaemia  and  spanaemia  as  be- 
ing part  causes  of  the  insomnia  of  continued  fevers. 
Emphasize  as  we  may  the  poisoned  condition  of  the 
blood  and  the  abnormalities  of  the  circulation,  the 
fundamental  factor  in  the  insomnia,  headache,  jactita- 
tion, delirium,  and  hebetude  of  continued  fever  is 
malnutrition  of  the  highest  nerve-centres,  and  against 
this  our  therapeutic  resources  are  meagre.  The 
necessity  of  nourishment  is  apparent;  but  little  food, 
however,  can  be  assimilated;  and,  in  the  absence  of 
any  specific  medication  (for  which  the  profession  is 
lool^ing),  the  best  that  can  be  done  is  judiciously  to 
combat  dangerous  symptoms  The  insomnia  is  the 
measure  of  the  cerebral  disturbance,  and,  if  this  can 
be  successfully  overcome,  one  important  obstacle  at 
least  in  the  way  of  recovery  is  removed. 

****•♦«•# 

[C  iapters  on  syphilis,  rheumatism,  gout,  and  lith- 


—  88  — 

(Btnia,  as  producers  of  insomnia,  were  originally  drafted, 
but  it  was  found  impossible  to  include  them  without  mak- 
ing this  volume  too  bulky.  A  treatise  on  all  the  causes  of 
the  derangements  of  sleep  would  comprehend  almost  the 
whole  of  internal,  and  even  surgical  pathology?^ 


a/ted, 
'  mak- 
tses  of 
>st  the 


CHAPTER  III. 

HYPNOTICS. 

The  limits  of  this  treatise  will  allow  of  only  a 
brief  consideration  of  the  leading  agents  that  properly 
come  under  this  head.  I  shall  take  up  first  the  med- 
icmal  hypnotics,  then  the  remedial  agents  not  med- 
icinal. 

I.      OPIUM   AND   NARCOTICS. 

* 

Opium  is  the  most  ancient  and  still  the  most 
universally  employed  hypnotic.  The  narcotic  prop- 
erty of  opium  is  the  result  of  its  morphine,  codeine, 
papavarme,  and  cryptopine— all  somniferous  alkaloids. 
Opium  IS  far  from  being  a  pure  hypnotic;  in  small 
doses  Its  action  is  that  of  an  excitant  of  the  cerebrum, 
and  generally  it  is  only  in  tolerably  large  doses  that 
It  IS  hypnotic.  Many  persons  find  opium,  and  espe- 
cially morphine,  powerful  promoters  of  wakefulness, 
sleep  only  following  many  hours  after  the  ingestion 
of  the  narcotic. 

Opium  is  par  excellence  the  hypnotic  where  the 
insomnia  is  due  to  pain.  Opium  undoubtedly  exerts 
Its  power  by  a  stupefying  action  on  the  cortical  cells, 
rather  than  by  any  changes  which  it  effects  in  the 
circulation. .  "  It  is  the  peculiar  virtue  of  narcotics," 
says  Still^,  "to  blunt  the  senses  and  steep  the  mind 
in  forgetfulness,  in  spite  of  pain,  of  nervous  irritabil- 
ity, or  of  tormenting  thoughts." 


—  90  — 
The  combination  of  opium  or  morphine  with  the 
pure  hypnotics,  as  chloral,  sulphonal,  paraldehyd, 
urethan,  is  often  highly  efficacious.  The  following 
formula  are  recommended:  (These  prescriptions 
are  designed  for  adults  only.) 

CHLORAL    ANU    MORPHIA. 

9     Morphina  sulph gr- ij- 

Hyd.  chloral 3  ij. 

Syrup  tolu 5  U- 

M.   Sig.— A  teaspoonful  when  needed  to  induce  sleep. 

PARALDEHYD  AND  TINCTURE  OF  OPIUM.' 

9     Paraldehyd 31. 

Tinct.  opiideod g«-  "*• 

M.   For  one  dose.     To  be  taken  in  a  little  old  rum  and 
water.     Valuable  in  the  insomnia  of  melancholia,   in  deli- 
rium tremens,  incipient  paralytic  dementia,  etc. 
SULPHONAL    AND    MORPHIA. 

Q     Sulphonal 3ss. 

Morph.  sulph gr.  X • 

M.   One  powder,  for  a  hypnotic  effect  where  there  is 
great  nervous  irritability  or  pain. 
MORPHINE  WITH   CHLORAL   AND   BROMIDE  OF   SODIUM. 

(From  Macfarlane.) 

B     Liqui  morphin    acet f3i. 

Hyd.  chloral 3i. 

Bromid.  sodii 3ij- 

Syrup  tolu 3iv. 

Aquam  add 3'*. 

M.  Sig.— Take  one-fourth  part  in  water  before  bedtime, 
and  repeat  in  two  hours  if  required. 


th  the 
lehyd, 
owing 
ptions 


;  sleep. 


um  and 

in  deli- 


there  is 
SODIUM. 


bedtime,. 


—  91    _ 

Other  narcotics-belladonna,  hyoscyamus,  Indian 
hemp,  stramonium— have  but  feeble  hypnotic  power 
They  are  not  absok.tely  devoid  of  this  power,  as  some 
writers  have  affirmed,  but  they  are  not  to  be  depended 
on. 

In  insomnia  due  to  genital  irritation  (such  cases 
as  sometimes  come  before  the  notice  of  the  physician 
in  connection  with  habits  of  masturbation  and  at- 
tempts at  reformation,  or  in  continent  young  men 
who  are  kept  awake  by  troublesome  erections),  also 
m  the  insomnia  produced  by  gonorrhceal  chordee, 
hyoscyamus  is  often  of  real  efficacy.  The  camphor 
and  hyoscyamus  pill  is  # convenient  formula: 

8     Pulv.carnph g^.  i. 

Ext.  hyoscyam gr.  iij. 

M.  For  one  pill.  To  be  taken  ^t  bedtime.  A  supposi- 
tory of  ext.  hyoscyamus,  3  grains,  and  pulv.  opii  i  grain, 
with  cacao  butter,  may  be  often  used  to  advantage. 

In  chordee,  I  have  given  teaspoonful  doses  of 
tincture  of  hyoscyamus  three  times  a  day  without 
producing  any  troublesome  dryness  of  i  he  mouth  and 
throat  or  dilatation  of  the  pupils,  ard  seen  quiescence 
and  sleep  follow. 

Lettuce  and  hops  possess  true  hypnotic  virtues, 
with  mildly  stupefying  properties,  and  do  not  produce 
any  arterial  or  cerebral  excitement  or  delirium,  or  any 
subsequent  paralysis  of  nervous  or  muscular  function 
like  other  narcotic  agents,  and  particularly  opium  and 
belladonna;  they  act  in  this  respect  more  like  chloral 


—    f)2    — 

and  paraldehyd  than  like  opium,  engendering  a  calm 
which  soon  passes  into  natural  sleep. 

I  know  certain  aged  patients  who  sleep  poorly  in 
consequence  of  cerebral  arterial  degeneration,  but 
who  affirm  that  when  they  are  able  to  indulge  free  y 
in  lettuce  as  an  article  of  diet,  they  sleep  very  well. 
I  have  not,  however,  seen  the  least  hypnotic  benefit 
from  any  pharmaceutical  preparation  said  to  contam 
lettuce. 

HOPS-LUPULIN. 

I  have  known  simple  insomnia  from  neurasthenia, 
from  care,  worry,  overwork,  etc..  temporarily  relieved 
by  teaspoonful  doses  of  lupulin  on  retirmg.     I  say 
temporarily,  for  I  have  never  known  the  effect  to  last 
longer  than  two  or  three  nights.     The  doses  must  be 
rather  large.     Hop  tea  can  be  of  little  use,  as  hops 
do  not  yield  their  active  principle  to  water.     Lupuhn 
is  a  yellow  powder  formed  on  the  surface  of  the  scales 
of  hops;  it  is  obtained  by  rubbing  or  threshmg  or 
sifting  the  strobiles,  of  which  it  constitutes  from  one- 
sixth  to  one-tenth  by  weight.     It  contains  a  volatile 
oil  and  bitter  principle  which  are  readily  soluble  in 
alcohol.     Lupulin  may  be  given  in  pill  form,  or  be 
taken  in  the  form  of  a  paste,  mixed  with  water  or 

syrup.  .  .    .    . , 

Doubtless  in  cases  of  insomnia  from  irritable 
bladder,  and  from  genital  irritation,  nearly  all  practi- 
tioners have  occasionally  found  lupulin  in  teaspoonful 
doses  useful. 


I 


I  calm 

jrly  in 
n,  but 
freely 
f  well, 
benefit 
contain 


ithenia, 
elieved 
I  say 
to  last 
nust  be 
IS  hops 
Lupulin 
e  scales 
hing  or 
>m  one- 
volatile 
luble  in 
1,  or  be 
water  or 

irritable 
1  practi- 
spoonful 


—  93  - 

It  will  not  do  in  closing  this  topic  to  omit  to  men- 
tion the  hop  pillow,  which  has  sometimes  proved 
beneficial  in  allaying  restlessness  and  producing  sleep 
in  nervous  disorders.  The  pillow  should  be  moistened 
with  spirits  before  being  placed  under  the  head  of  the 
patient  (Dr.  Geo.  B,  Wood). 

Pills  for  Satyriasis  {Dujardin-Beaumetz). 

''"P"Hn 2  grammes. 

Bromide  potassium 2  grammes. 

Ext.  nymphaea (water  lily),   q.  g. 
For  2o  pills.     Sig.     Take  two  pills  every  two  hours. 

II.      ALCOHOL,    AND   OTHER    STIMULANTS -EUPEPTIC 
AGENTS. 

Alcohol  sometimes  acts  as  a  hypnotic,  and  is  in 
fact  frequently  resorted  to  for  that  purpose.     It  pro- 
duces sleep,  not  because  it  is  a  vascular  stimulant, 
clearing  the  over  distended  blood-vessels,  but  because 
it  is  taken  in  a  sufficient  dose  to  have  a  narcotic  effect. 
Ale  is  especially  chosen  for  hypnotic  effect;  the  hops 
with  which  it  is  impregnated  undoubtedly  aid  the  calm- 
ative action.    Whiskey  or  brandy  to  have  a  soporific 
effect  should  be  of  pure  quality,  and   the  older  the 
better.   The  theory  that  liquors  long  mellowing  in  the 
cask  get  rid  of  fusel  oil  and  other  alcohols  notethylic, 
and  develop  soothing  ethers,  seems  actually  sustained 
by  facts;  certain  it   is,   moreover,    that   new   liquors 
adulterated   with  the  higher  atomic  and  more  fiery 
alcohols  are  excitant,  and  therefore  antagonistic  of 


') 


"I'l I iiii'iii I  rii  iiitiMiiiilit;. 


-— ««»^^«.«' 


f 


ife 


—  94  — 
sleep.  A  tablespoonful  or  two  of  pure  whiskey  taken 
on  going  to  bed  will  often  relieve  the  insomnia  of  the 
exhausted,  the  irritable,  the  nervous;  the  insomnia 
due  to  mental  overwork  or  worry  will  often  promptly 
yield  to  the  alcoholic  potion.  It  is  weP  to  administer 
the  spirit  in  a  tumbler  of  hot  water -as  hot  as  can  be 
drunk— as  the  heat  favorably  excites  the  stomach,  and 
through  that  organ  reflexly  soothes  and  inhibits  the 
cerebrum. 

U  nfortunately,  the  sleep  produced  by  alcohol  is  often 
of  short  duration;  the  patient  awakes  after  a  couple  of 
hours  but  little  refreshed,  and  may  lie  awake  much  oi' 
the  night  without  being  able  to  go  to  sleep  again. 
The  combination  of  whiskey  with  a  little  sulphonal 
may,  however,  remedy  this.      The  sulphonal  may  first 
be  taken  in  fine  powder,  well  stirred,  till  it  is  about 
the  thickness  of  cream,  into  a  little  water;  this  is  fol- 
lowed by  the  draught  of  whiskey.     When  the  effects 
of  the  alcohol  begin  to  subside,  those  of  the  sulphonal 
(which  is  slow  to  undergo  absorption)  are  just  com- 
mencing.    I  have  known  a  dose  of  only   lo  grains  of 
sulphonal,  followed  by  a  tablespoonful  of  old  whiskey 
in   a  little  hot  sweetened  water,  to  oe  succeeded  by 
eight  hours  of  sound  sleep. 

Ginger,  peppermint,  camphor,  lavender,  carda- 
mom, and  other  gastro-intestinal  stimulants  and 
"carminatives,"  taken  with  hot  water,  occasionally 
prove  hypnotic.  Even  hot  water  alone  may  induce 
sleep  if  drunk  freely  on  going  to  bed;  in  such  cases 


I  taken 
I  of  the 
somnia 
omptly 
ninister 
can  be 
ich.and 
aits  the 

lis  often 
juple  of 

TlUCh  Ok 

)  again, 
ilphonal 
lay  first 
is  about 
s  is  fol- 
;  effects 
alphonal 
ist  com- 
jrains  of 
whiskey 
;eded  by 

r,  carda- 
ints  and 
;asionally 
y  induce 
uch  cases 


—  95  — 

it  may  be  supposed  that  the  insomnia  is  the  result  of 
a  dyspept.c  state,  and  that  the  increased  vasculariza- 
tion  of  the  stomach  may  cause  diminished  vasculariz- 
at.on  of  the  brain,  thus  producing  one  of  the  condi- 
tions  of  sleep.  A  few  drops  of  the  aromatic  spirits  of 
ammoma,  of  the  ammoniated  tincture  of  valerian,  of 

he  fluid  extract  of  skullcap,  will  sometimes  enable 
the  mdiv.dual  speedily  to  pass  the  barrier  which  sep- 
arates the  waking  from  the  sleeping  state.  Many  a 
person  rendered  sleepless  by  a  disordered  stomach- 
the  seat  of  acrid  fermentations-has  been  enabled  to 
realize  immediate  quiescence  of  both  stomach  and 
brain  by  a  dose  of  rhubarb  and  soda,  a  drachm  of 
Carlsbad  salt  in  a  cup  of  hot  water,  or  even  the  same 
quantity  of  bicarbonate  of  sodium  taken  in  the  same 
wsy, 

m.      BROMIDE  OV  POTASSIUM  AND  I.ROM.DES. 

hrnmtTT  "l'  "'''"'  ''^P"°''''  '""^^  ^e  mentioned 
bromide  of  potassium,  which  still  has  a  great  reputa- 
tion  as  a  remedy  for  chronic  insomnia.  It  probably 
produces  its  effects,  as  Vulpian  taught,  not  by  an«mi 
ating  the  cortex,*  but  by  the  influence  which  it  directly 
exerts  on  the  anatomical  elements,  "it  «|mply  less- 
ens the  functional  activity  of  the  brain,  without  dis- 
m '"^1  '■'^'"°"  °^  °"'  P^"  *°  ^"°'her"  (Brunton). 
,W  K  r?'  '  u"'"°"  ''  '°  ^'™'"'«h  cerebral  or  spinal 
'"'^^^"'^y'  ^'^^^^  th«  brain  is  hyper^mic  from  excess 

*I.e(ons  sur  les  Vaso-moteurs,  t.  ii,  chap.  i. 


_  96  - 

of  mental  toil,  from  prolonged  watching,  from  abuse 
of  stimulants;  in  nervous  erethism  characterized  by 
emotional  excitability,  exaggeration    of    the    reflex 
activity    in  the  insomnia  of  fevers,  and  m  genito- 
urinary insomnia,  bromide  of  potassium  (at  least  till 
the  discovery  of  chloral)  has  been  the  best  hypnotic 
known  to  the  profession.     It  depresses  innervation 
generally,  and  is  a  debilitant  of  the  heart;  hence,  m 
the  feeble,  asthenic,  and  cardiac,  it  is  to  be  prescribed 
with  caution.     It  may  often  with  advantage  be  asso- 
ciated with  chloral    and    morphine;    if  given  with 
whiskey  its  depressant  action  is  less  marked;  the  com- 
'bination  with  calisaya,  with  simple  elixir,  with  anise 
cordial,  makes  it  often  more  acceptable  to  the  stomach. 

I^     Pot.  brom grs.  xxx. 

Anise  cordial 2  '• 

M.     For  one  dose. 

9     Pot.  bromid S^s. 

Elix.  calisaya,  1 fta  5  it). 

Sherry  wine,     )  ■,       u  a 

M.     Sig.:  Ateaspoonfulthreetiinesadayandatbed- 

time.  . 

5     Poi.  bromid.,  ) aa3ij. 

Hyd.  chloral,  ) 

•  Tinct.  valerian 3  ^*' 

Spts.  lavend.  co 3  vi. 

Aquaecamph q.  s.  ad  5  vi. 

M.     Sig.;  A  tablespoonful  everytwo  hours  till  sleep  js> 

induced. 
The  above  formula  has  been  of  great  use  to  me 
in  the  treatment  of  alcoholic  insomnia. 


abuse 
ed  by 
reflex 
renito- 
ist  till 
pnotic 
•vation 
nee,  in 
scribed 
;  asso- 
n  with 
le  com- ' 
1  anise 
omach. 


d  at  bed- 


11  sleep  is 
56  to  me 


t 

—  97  — 

BROMIDE   OF    LITHIUM. 

The  bromide  of  lithium,  according  to  Macfar^ 
'  lane,  is  the  best  hypnotic  of  the  bromide  salts  as  it 
contains  a  half  more  bromine  than  the  potassium  bro- 
mide. Its  dose  is  ID  to  2o  grammes.  Macfarlane 
recommends  the  combination  with  ergot  of  rye  and 
digitalis,  both  of  which  are  stimulants  of  the  vaso- 
motor centres. 

^    Bromidi  lithii ,  ^^   ^^j 

Fluid  ext.  ergot [  3  i. 

Tinct.  digitalis n,  xx. 

Chloroform  water 3  xv 

h-i      ^"  u^'^'i  ^"^^  one-half  tv;o    hours  before  goitiK  to 
bed,  and  the  other  half  at  bed-time.* 

IV.      CHLORAL. 
The  discovery  by  Liebreich,  in  1869,  of  the  hvo- 
notic  properties  of  hydrate  of  chloral  may  be  regarded 
as  one  of  the  most  important  therapeutic  discoveries  of 
modern  times.     The  experience  of  the  past  twenty-two 
years  has  more  than  justified   the  first  conclusions 
respecting  its  actions  and  uses,  and  chloral  may  still 
be  regarded  as,  on  the,  whole,  the  best  hypnotic  we 
possess.     Its  principal  advantages  are:  i.  It  is  speedy 
and  generally  certain  in  its  action.     2.  There  is  no 
pre  iminary  period  of  excitement.    3.  Its  effects  are    ' 
prolonged,  and  the  sleep  wnich  it  produces  is  calm 
tranquil,  and  refreshing;  the  patient  wakes  out  of  the 

•  Wmnia  and  Its  Therapeutics,  p.  88. 


■| 


■iMiiniii  j.'mi 


w? 


I: 


-98- 
chloral  sleep  as  out  of  natural  sleep.     4-  It  can  be 
eiven  with  good  results  in  cases  where  opium  is  not 
tolerated     S.  There  are  seldom  any  unpleasant  or  m- 
urious  after-effects;  it  does  not  disturb  the  secretions 
ir  excretions,  as  do  many  other  hypnotics.     6.  It  has 
a  wide  range  of  usefulness  besides  being  simply  a 
sleep-producer;   in  all  morbid  cerebro-spmal  condi- 
tions attended  with  excitation,  delirium,  or  spasm,  it 
is  markedly  beneficial;  in  the  insomnia  due  to  delirium 
tremens,  alute  mania,  general  paralysis  of  the  insane 
puerperal  mania,  chorea,  tetanus,  etc.,  it  is  of  great 

''*^"  Among  its  disadvantages  are:      i.  It  is  a  cardiac 
depressant,  and  therefore  must  be  given  with  great 
caution,  or  withheld  in  organic  affections  of  the  hearty 
,  It  is  a  dangerous  remedy  when  long-contmued,  its 
effects  on  the  brain,  and  consequently  on  the  .cental 
functions  and    disposition,   being    deplorable.    The 
.Moral  haUt  is,  doubtless,  quite  as  bad  as  the  morphine 
habit      "  Its  employment,"  says  Mucfarlane,  "is  so 
fraught  with  risk  that  its  use,  except  under  medical 
advice,  is  much  to  be  deprecated 

«  At  first  the  mental  depression  and  melancholia, 
from  which  the  patient  suffers  »J«  ^"^'^'^'^^^^y  J 
.  doae  of  the  drug;  after  a  time  it  fails  to  soothe,  and 
may  even  excite.  The  victim  gravitates  into  a  pitia- 
ble state  of  mental  weakness  and  demoraluation,  be- 
coming childish,  vacillating  and  untruthful,  some- 
t^es  dejected,  at  other  times  excited,  and  having 


K- 


EJ^CT^ 


:an  be 

is  not 
t  or  in- 
retions 

It  has 
mply  a 

condi- 
)asm,  it 
lelirium 

insane, 
f  great 

cardiac 
h  great 
le  heart, 
nued,  its 
!  mental 
le.  The 
norphine 
;,  "is  so 
medical 

ancholia, 
ted  by  a 
othe,  and 
3  a  pitia- 
ation,  be- 
ul,  some- 
d  having 


—  107  — 

and  almost  everybody  has  experienced  the  difficulty 
of  going  to  sleep  when  the  feet  are  cold.*  ' 

The  Wet  Pack.~i:\i\$,  is  a  very  active  hydro- 
therapic  method,  being  a  "derivative  or  calmative 
of  the  highest  order"  (Macfarlane).f  A  sheet  is 
wrung  out  of  cold  water,  and  the  patient  is  enveloped 
in  it  from  neck  to  ankles,  the  head  and  feet  not  being 
included.  Several  dry  blankets  are  wrapped  around 
the  patient,  a  hot  water  bag  is  applied  to  the  feet,  a 
cold  wet  cloth  to  the  forehead,  and  the  patient  is 
allowed  to  remain  in  the  pack  from  half  an  hour  to 
an  hour.  At  »he  end  of  the  process  he  is  rubbed 
down  with  dry  cloths  to  promote  vigorous  reaction. 

The  Turkish  Bath.— The  Turkish  bath  is  highly 
recommended  in  many  cases  of  insomnia.  It  relieves 
cerebral   congestion,  and   promotes  circulation   and 

*Hemmond  employed  with  success,  in  a  young  girl 
whose  extremities  were  habitually  cold,  electrization  of  the 
sciatic  nerve. 

t  Experiments  of  Weir  Mitchell  have  shown  that  the 
effect  of  chilling  the  cerebrum  is  a  brief  sedative  action. 
Then  phenomena  of  motor  excitation  are  developed,  sensi- 
bility is  lessened,  and  if  the  application  of  cold  is  continued, 
the  animal  falls  into  a  profound  stupor,  and  surgical  opera- 
tions may  be  performed  on  him  without  the  least  movement. 
When  cold  is  applied  to  the  medulla  oblongau,  the  respira- 
tory movements  are  first  tumultuous,  then  they  are  slowed, 
and  finally  cease  altogether.  (Quoted  from  "  Clinical  Theral 
peutics,"  by  Dujardin-Beaumetz.  Published  by  G.  S.  Davis, 
Detroit,  Mich.) 


^\f' 


•:m 


N- 


II 


—  io8  — 
irterial  tone,  as  well  as  digestion  and  assimilation. 
The  Turkish  bath  consists  of  three  rooms.     The  tem- 
perature of  the  first,  or  dressing  room,  is  moderate, 
that  of  the  second  is  higher,  that  of  the  third  is  higher 
still.     In  the  first   room,  the  bather,  after  dressmg,  , 
winds    one    towel    around   his  loins  and  a  second 
around  his  head  in  the  form  of  a  turban.  If  he  has  any 
tendency  to  cerebral  congestion,  the  second  one  may 
be  wet.     He  then  passes  into  the  second  room,  where 
he  waits  a  short  time  before  passing  into  the  third 
room.  Some  people,  however,  go  directly  into  the  third 
room.    In  both  the  second  and  third  rooms  the  bathers 
partake  freely  of  cold  water.     A  few  minutes'  stay  m 
the  warmest  room  is  usually  sufficient  to  make  the 
bather  perspire  freely,  and  he  then   returns  to  the 
second  or  cooler  room,  where  he  may  remain  half  an 
hour  or  more,  according  to  circumstances.     He  may 
then  be  shampooed,  the  surface  of  the  body  bemg 
rubbed,  the  muscles  kneaded,  and  the  smaller  jomts 
extended.    He  is  then  washed  with  a  lather  of  soap, 
and  sluiced  with  basins  of  tepid  or  warm  water.      For 
some  people^  it  is  most  agreeable  after  this  to  be 
simply  wrapped  in  warm  towels  and  allowed  to  repose 
in  the  dressing-room.    Others  prefer  to  finish  up  with 
a  cold  douche  before  proceeding  to  the  dressing-room. 
Here  they  remain  resting  for  a  considerable  time  be- 
'     fore  they  again  dfess.* 


*Brunton*8  Pharmacology  and  Materia  Medica. 


ition. 
tem- 
;rate, 
igher 
ssing, 
scond 
IS  any 
•  may 
ivhere 
third 
:  third 
others 
tay  in 
;e  the 
o  the 
alf  an 
e  may 
being 
joints 
soap, 
For 
to  be 
repose 
ip  with 
[-room, 
me  be- 


—  109  — 

Hot  Compresses,  consisting  of  layers  of  flannels 
wrung  out  of  hot  water  and  covered  with  dry  flannels, 
are  sometimes  of  benefit  in  insomnia  when  applied 
over  the  abdomen. 

In  an  interesting  lecture  recently  published  in 
the  Dietetic  Gazette  (Dec,  1891),  Dr.  C.  L.  Dana,  in 
speaking  of  the  benefits  of  hydrotherapy  in  nervous 
diseases,  regards  the  wet  pack  as  a  most  useful  seda- 
tive in  neurasthenia  and  insomnia,  and  a  good  sub- 
stitute for  medicinal  sedatives,  like  the  bromides.  It 
should  be  given  three  or  four  times  weekly,  or  for  a 
short  time  daily.  The  tepid  bath  ranks  next  in  its 
sedative  efficacy.  The  shower  and  jet  baths  are  a 
most  valuable  meaps  for  securing  tonic  effects. 

In  weak,  sensitive  and  anaemic  women,  he  pre- 
scribes, first,  dry  hot  packs  for  a  week,  then  wet  packs, 
and,  finally,  the  drip  sheet  or  cool  shower.  The 
Turkish  bath  and  the  hot  Sitz  bath  (the  patient  sitting 
for  twenty  to  thirty  minutes  in  water  at  blood  heat) 
have  also  been  found  to  have  excellent  sedative 
effects  and  to  be  promotive  of  sleep.        • 

Electricity.— M.y  experience,  like  that  of  most 
general  practitioners,  has  been  confined  to  faradism; 
I  have  resorted  to  this  form  of  electricity  for  the  re- 
lief of  obstinate  insomnia.  I  have  never  applied  the 
current  to  the  head,  but  have  sought  to  obtain  a 
powerful  derivative  effect  by  applications  of  the  wet 
sponge,  or  the  metallic  brush,  to  distant  parts  of  the 
body.    I  have  seen  neurasthenic  patients  quieted  and 


■}!■!(■ 


_■ 


^  —  no  — 

made  able  to  sleep  by  faradization  up  and  down  the 
spine  about  bed-time;  also  by  a  general  electric  mass- 
age, given  with  the  hand,  which  is  made  to  communi- 
cate the  current. 

Stills  (Therapeutics  and  Materia  Medica)  speaks 
of  obtaining  success  "  by  passing  a  fine  secondary  or 
primary  current  from  the  cervical  vertebrae  to  the 
epigastrium,  and  from  the  dorsal  vertebrae  to  the  en- 
tire front  of  the  chest."  "  Drowsiness,"  he  adds,  "  is 
not  uncommon  in  anaemic  and  debilitated  persons 
during  the  use  of  a  generally  applied  direct  inductive 
current.  It  has  occurred  only  under  the  influence  of 
a  fine  interrupted  current  of  the  second  order,  with  a 
low  intensity.  In  old  persons  who  are  restltess  and 
sleep  badly,  a  current  of  this  kind  passed  over  the 
forehead,  while  the  negative  is  carried  over  the  shoul- 
«ers  and  down  the  arms,  quickly  promotes  sound  and 

prolonged  sleep." 

Doubtless  cutaneous  faradization  produces  that 
anaemic  condition  of  the  encephalon  which  is  favora- 
ble to  sleep;  in  confirmation  of  the  view  that  this  is 
the  case,  we  have  the  observation  of  Nothnagel  that 
"  cutaneous  electrical  stimulation  is  followed  by  a  re- 
flex contraction  of  the  vessels  of  the  pia  mater." 

Central  galvanization  has  proved  efficacious  in 
the  experience  of  Berdet,  Meyer,  Erb,  Skene,  Keith, 
Macfarlane,  and  others.  According  to  the  experi- 
ments  of  Legros  and  Onimus,  currents  of  descending 
direction  (positive  pole  over  the  forehead,  negative 


—  Ill 


i.the 
nass- 
nunl- 

)eaks 
ry  or 
)  the 
e  en- 
s,  "is 
Tsons 
ictive 
ice  of 
vith  a 
s  and 
er  the 
shoul- 
d  and 

s  that 
avora- 
this  is 
el  that 

y  a  re- 

»» 

ous  in 
Keith, 
experi- 
ending 
egative 


pole  to  the  neck)  determine  contraction  of  the  vessels 
of  the  pia  mater;  reverse  the  poles,  and  a  directly 
contrary  effect  is  obtained. 

Doubtless  electro-therapeutists,  by  their  ready 
control  (through  the  proper  currents)  of  the  vaso- 
motors, are  able  to  modify  the  intra-cranial  circula- 
tion at  will,  and  if  sleep  were  only  a  circulatory  phe- 
nomenon, they  would  be  able  to  give  us  infallible 
recipes  for  all  kinds  of  insomnia.  Unfortunately  the 
laws  of  natural  sleep  are  not  exactly  the  same  as  the 
laws  of  the  vaso-motors:  sleep  is,  as  has  before  been 
said,  something  more  than  a  plus  or  minus  of  blood 
in  the  brain.  If  galvanism  is  a  remedy  for  insomnia, 
it  is  by  improving  the  tone  of  the  vessels,  and  the 
nutrition  of  the  cerebral  cells,  rather  than  by  any 
transient  influence  on  the  circulation,  that  it  does 
good. 

The  subject  is  one  on  which  a  long  chapter 
might  be  written,  but  such  a  chapter  would  be  inap- 
propriate for  this  treatise.  The  successful  treatment 
of  insomnia  by  galvanism  presupposes,  on  the  part  of 
the  practitioner,  a  knowledge  of  technical  details  and 
a  skill  which  can  only  be  acquired  by  a  study  of  the 
best  special  treatises  on  electro-therapeutics  and  by 
long  practice.  Moreover,  the  range  of  usefulness  of 
electricity  in  insomnia  is  largely  limited  to  neuro- 
pathic or  neurasthenic  cases. 

Lewancjowski  and  Eulenburg  state  that  they 
have  obtained  very  favorable  results  with  franklini- 


km 


—    112    

zation.    The  head  plate  is  used,  and  the  electricity  if, 
conveyed  in  the  form  of  breezy  currents  which  are 
both  agreeable  aud  soothing  to  the    patient.    By 
means  of  the  discharging  hand  electrode,  the  patient 
is  also  electrified  through  his  clothes;  the  stances  last 
about  half  an  hour,  and  the   patient  goes  to  bed 
soothed  and  ready  to  go  to  sleep.    At  the  Adams 
Nervine,  Jamaica  Plain,  much  account  is  made  of 
static  electricity  in  the  treatment  of  nervous  insomnia, 
and  my  friend  Dr.  B.  W.  Bartlett,  of  Rowley,  informs 
me  that  he  relies  principally  on  this  form  of  electric- 
ity (along  with  other  hygienic  means)  in  the  treatment 
of  neurasthenia  and  its  accidents,  insomnia  included. 

To  conclude  the  chapter  on  Hypnotics— if  drugs 
have  had  the  greatest  prominence  among  the  thera- 
peutic means,  it  is  not  because  they  are  really  the 
most  important.    I  think  that  physicians  should  >e 
very  chary  in  prescribing  the  medicinal  hypnotics.  We 
still  know  too  little  about  their  action  on  the  delicate 
cells  of  "the  brain  and  on  the  vaso-motors.     Many  of 
them,  by  constant  or  frequent  use,  become  positively 
baneful     It  is,  therefore,  with  a  caution  agamst  the 
careless  employment  of  hypnotics  that  I  close  this 
book  and  with  an  exhortation  to  physicians  first  to 
try    fully    (when    possible)    all    available    hygienic 
resources  before  resorting  to  medicinal  hypnotics. 


:ity  If. 
h  are 
.     By 
atient 
•8  last 
3  bed 
idams 
de  of 
imnia, 
iforms 
ectric- 
itment 
luded. 

■  drugs 
thera- 
lly  the 
luld  be 
ics.  We 
lelicate 
lany  of 
isitively 
inst  the 
}se  this 
first  to 
lygienic 
lotics. 


INSOMNIA. 


S^Se^o?^i^''P'■""'^•  J'  "^''«'«  ""f««   «"»   from 
V  .     'ISY*"  *°  create  us  anew  from  dav  to  dav  "     ir  •«  i„ 
deed  "  Tired  Nature's  sweet  restorer."  ^  ^"  ''  '"" 

Insomnia  may  be  dependent  upon  deraneement  of  thi. 

.ar7S,T'S'  '"""""°7  r,"''"""  -"«'"'"«  -li"  " 
lary  tract,  the  liver,  or  upon  febr  e  or  eeneral   diooae*      t» 

i'SJ^tn^ih  '""!?'  ^y  ""^J'*'*"'^  condition""  heangHigh 
ing,  ventilation,  diet,  or  occupation  "^-''''K.  "gni 

Whatever  its  cause,  which  must  be  sought  for  and  as  far 
as^po^sible  removed,  resort  must  often  be^ad  to  medicinal 

.nH  S"*Pf  **'ons  Of  the  Bromides,  Chloral,  Gelsemium  Ooium 
and  Henbane  are  most  universal  y  employed.  ^ 

undelt'hSriVSf''  *"  ^°"^'"^^'°"  '"  '-0  different  formula, 

CEREBRAL  SEDATIVE  COMPOUND 

(Formula  A,  with  Opium;   Formula  B,  with  Henbane  sub«ti 

Sat'eJ)'"''"""'  ''*'  '*""  ^^^  '^'^'^  •"  *»'-•'  Opiu  "i:  cotra: 

istratkllf:  ^°"°'''"«  prescription  is  an  eligible  one  for  admin- 

9     Cerebral  Sedative  Compound, 

Syr.  Sarsaparilla  Compound,  aa  ?  iv 
P..  D.  A  cc's.     , 
Sig.:     Dessertspoonful  when  indicated. 

on  re^S?""  "'""""  °'  °°'  ''""''^'  '""  ">  Phy'ician. 

PARKE,  DAVIS  &  COMPANY, 

DETROIT   AND    NEW   YORK. 


'I 


1 —  i 


«.    Mnnthlv  Journal  or    t»ny»i"'"w 

A  Monthly  C.M..«.-  ^:-;J;/i!;S«  ;rn,«cr.os  o. 

DR.  JOHH  S.  BILHN08    Sur,.on^a  a,^A^.  pi^BXCHER.  M^R.  C.  H..  En,. 

9UB9CH.PT.ON    PH.CE.    ''OOO    PER    YEAR. 

THB    AIMRIOAN    LANOWT. 

'  "••;s;iWRTT7o'-N°p";:rcr."o;  p.«  v«». 

TBB    MBDICALi    AQB. 

BDITCD  BY  ,         Tur       D 

*  n'JSSR.PT^oV'pmCE;  •..OO    PER    YEAR. 

BDIWD  BV  -n,      D 

'  -|SSJo^^pV.SS''pR.§L  r.So  PER  V«P. 

OTB  Btrturam  or  pkxbmaot. 

A  Monthly  Expon-nt  of  Ph«rn«o  ^    ^^^^ 

SUBSCRIPTION    PRICE,    9i-» 

~~;i;;aroneToun«i.  and  »cco.np«.ylng  8U»«oripUon 

•nd  AOB.»M-.:^S  te«  tSS  ««^^  rrte..      . .  ^  ..^^„  „,  current  med»- 

0BO.  8.  DAVIS.  PubllsHer.  Detroit.  MloH. 


T 


0N3 


»r. 


rapautloa. 

M    0. 

f  th«  World. 
I.e.  »..«"«• 


IBDICINB. 


eil  News 

:ar. 
BR. 

3RESS. 
<R. 


and  N«w«. 
AR. 

^Ing  subaoripUon 

$4.00;  LANCET 
TIN  with  any  of 

of  current  meiU- 
»rogi'<*«- 

>it.  Mioli. 


IN    EXPLANATION 

OF 

Bie  Pliyslms'  Leisure  litoary. 

We  have  made  •  new  departure  in  the  publication  of  medioal  books.  A*  70U 
no  doubt  know,  lunnr  of  the  lante  treatiiee  publiahod,  which  lell  for  four  or  (Iv*  or 
more  dollara,  conuin  much  irrelevant  matter  of  no  pra<<tloal  value  to  the  phyil. 
clan,  and  Iheir  hlxh  price  make*  It  often  Impoeslble  for  the  avenwe  practitioner  to 
purobaM  anythlnn  like  a  complete  library. 

BellavlnR  that  short  practical  treatise*,  prepared  by  well  known  authors,  con. 
talninft  the  iri*t  of  what  they  had  to  say  reKardlng  the  treatment  of  dl*eaaea  com- 
monly met  with,  and  of  which  they  had  made  a  ipeoial  *tudy,  sold  at  a  small  price, 
would  be  welcomed  by  the  majority  of  the  profession,  we  have  arranfed  for  Um 
pubUoaUon  of  luoh  a  lerle*,  csllInK  it  The  Phyalelana*  Lelsur*  Library. 

This  series  has  met  with  the  approval  and  appreotation  of  the  medical  profu- 
sion, and  we  shall  continue  to  issue  In  it  books  by  eminent  authors  of  this  country 
and  Europe,  covering  the  best  modem  treatment  of  prevalent  diseases. 

The  series  will  certainly  afford  practitioners  and  students  an  opportunity 
never  before  presented  for  obtaining  a  working  library  of  books  by  the  best  authors 
at  a  price  which  placee  them  within  the  reach  of  aU.  The  books  ai«  amply  illus- 
trated, and  issued  in  attractive  form. 

They  may  be  had  bound,  either  in  durable  paper  covers  at  3A  Ota.  per  copy, 
or  In  cloth  at  50  Ota.  per  copy.  Complete  aeries  of  19  books  In  sets  as  announosd, 
at  $S.  50,  In  paper,  or  cloth  at  $5.00,  postage  prepaid.     See  complete  list. 


PHYSICIANSM^EISURE  LIBRARY 

PBICEi   PAPER,  25  CTS.  PER  COPY,  S2.50  PER  8ET1  CLOTH,  30  CT8.  PER  COPY, 

ft9.00  PER  SET. 


lnhalsri.lnhalatloniand  Inhalant*, 
^y  Beverley  Robrnton,  M.  D. 

The  U**  of  Elsotrioity  In  th*  Removal  of 
•upsHluou*  Hair  and  the  Trsstment  of 

^'fi?'8j;"ifin%*'P».D. 
Nsv»  Msdioation*.  Vol.  I. 

By  Dttjardin-Beaumctt,  M.  D. 
Nevv  Msdloatlont.  Vol.  II, 

By  Oajardia-Beaumetx,  M.  D. 

^"•eT^issSeTavsnrM"'""-" 


SERIES  I. 

Antlisi 


lenry  j!  Uttriguc*,  M.  D. 

On  th*p*t*rminstion  of  ths  Necestity  for 
Wearing  Ola**e*. 

By  O.  B.  St.  John  Rooss,  M.  D. 
Th*  Phy*lologloal,Patholeglcal  and  Thar- 
*p*utlo  Eff*et*  of  Coinpr****d  Air. 

By  Andrew  H.  Smith,  M.  D. 
QrsnulsrLid*  and  eentagiou*pphthalmls. 

By  W.  P.  Mittcndwl,  M.  D. 
Practlcsl  Bsctsriology. 

ByThoma*  B.  Satterthwaile.  M  D. 
Pragnanoy,   Parturition,  th*    Pu*rp*ral 

•ii?K'ui'V:"Nfifn'a8!'iif!'B"*- 


8EKIB8  11 


Th«OlM«o»l»  Md  TrMlmtM  of  H«»m- 

■y  ChM.  B.  KtlttT.  M.  D. 
OlMtMi  of  ikt  Htan,  V«l>  l<      - 

OlMJHief  tht  Mj»ii,  Vol.  H. 


TM  ioVow  Tr..t"..M  •♦  OLrrh...  .«d 
^;rB    P....r.  M    D 


By  AUan  McL»nt  H»«lUoo.  M.  w. 
Th.  Modorn  TrtMmtnt  of  H.-ft.y  tnd 

^WM"G.,U«d.M,D, 
OlMM..oftMM«ltOro!hrj. 
By  Ptwondon  N.  Otw,  M.  u- 

Th.  Oliofdor.  of  '"•"•''-'"•J'  I, 
By  Bdw»rd  W.  Jtnlu.  M.  u. 

TM  Inftotlout  DlMMO*.  Vol.  •• 
By  Karl  LlebormolMtr. 

Tht  InfooliOM  OiMiMt.  Vol.  H. 
By  K»fl  l.l«b«rmelit«'. 


8BB1ES  III. 


D. 


AbdemintI  •iirftry. 

By  Hal  C.  Wyman,  M. 

OlttawtofthoUvor. 

By  Dujardln-Boauowti,  M.  u- 

By  J.  teooard  Corning,  M.  O. 
OlWMiofthoKldBiy. 

By  DuJ»rdln-B««um«ti,  M.  D. 
Th.  Thoory  and  Praetio.  ot  th.  Ophth.l- 
•"BrrH.rb«rtCUlborn..Jr..M.D. 

Nlod.rn  Tr.atm.nt  of  Bright'.  Ol.w... 
ByAlfr.dU.  Looml.,  M.  D. 


Ollnloal  L.ctur..  on  C.rtain  Oi..a»..  of 
"VfJo'Tm.  Charcot.  M.D. 

•"'"stwSV  Ha«-ond.  M.  D. 

•"'•'flTmnk  Woodbury.  M.D 
Th.  Tr.atm.ntof  th.  Morphia  Habit. 

By  Erlcnm*y.r. 
Th.  Itlology.  Olagnoii.  and  Th.rapyof 
TuborouloM  ,.,     __,_ 

By  HroJ.  H.Ton  Zl.BiM*n. 


SERIES  IV. 


,  and  Oultur.  ••.ear'*'**?'*  *' 
fthand  Dl«.a*.*of  Wom.n. 


•••TH*''£!"w;od.  M.  D. 

'^'^•Ut  crsioneTM.  D. 

^^%*k.  H.  smith.  M  D. 
ATr.atl..onF'aotur.j. 

Bt  Armand  Dwpr*.,  M.  u. 

ingtyplllH».„  „  r» 

Tiy  E.  L.  Keyta,  M  .D. 

Hypodarmio  M.dlcatlon. 
™  y  BoumoTllle  and  Brlcon 


WMa..»of  OWldr.n. 

By  I.  N.  Lot.,  M.  D. 
N.urali^a.     „     .  „  n 

Rhaumatitm  and  Oo"*;         „  « 
By  F.  Le  Roy  Saiwrl..,  M.  u. 

SLctricity.  It.  *PP"!«''»" ';,'*D*'*Tvrt  11 
By  W.Utaron Adam.,  M.D.    L*™-'" 

CLctrlcity,  It.  Appllc«t'o« '"  •^•'*  ^^1  jll 
ByWelUogtonAdamt,M.D.  ivoi.ui 

AuioMltatlon  snd  P.rcu..lon. 

By  Fredwck  C.  Shaituck,  M.  D. 


,| 


•tdaoiiM. 

Iltoo,  M.  D. 
Plturtty  M* 

t. 
t. 

M.  D. 
lon> 
M.  U. 
I.I. 

i.n. 


I.  M.  D. 
A.  M.,  M.  D., 


onrf,  M.  D. 

M.D. 

rphi*  Habit. 

«nd  Thtr»P)f  of 
kMca. 


Management  oi 


flea,  M.  D. 

M,M.D.    [Vo».Il 
on  In  Mtdljlna. 
ini,M.D.  IVol.ni 
iMion. 
Mituck,  M.  D- 


flRfllES    V. 


Tahlnc  Oolct. 

By  P.  W.  Hoiworlh,  M.  u 

Praotloal  NotM  on  Urinary  An«ly 

Hy  William  H.  CinHtld,  M.  D. 

Fraotloal  Intaatlnal  Sursary.  Vol.  i. 
'^raotloal  Intaatlnal  Bursary.  Voi.ii. 

»V  K    H   Koblnton,  M     D. 
'kaoturaa  on  Tumora. 

By  John  H.  Hamilinn,  M.  D.,  LL.  D. 

'Pulmonary  Oonaumptlon,  a  Mmf 
voua  Olaaaaa. 

By  Thoaa»  J .  MayH,  M  D . 

^aaaona    in    tha    Olagnoala    and 
Traatmant  of  Bya  Olaaaaaa. 
By  Catty  A.  Wood,  M    O. 


•laaaaas  of  tua  ■maaarand  ^roa* 

Ur  H»   r    Wyman.  M.  D. 

Artlflolai  Anaaatnatla  ana  An«ia« 
thatloa. 

Hy  ncKoreit  Wizard,  M.  0..and  tit 
Lewi*  H.  Adicr,  Jr. 

Oanoar. 

By  Danlal  t.twit,  M.  O. 

Tha  Modarn  Traatmant  of  Nip  Ola* 
aaaa. 

By  Charin  P.  Stillman,  M.  D.  < 

Inaomnia  and  Nypnotloa. 

By  Ganaain  it* . 

Tranilattd  by  B.  P.  Hurd,  M,  D. 


BOOKS  BT  LEADING  AUTHORS. 

SEXUAL  IMPOTENCE  IN  MALE  AND  FEMALE ti  oo 

By  Wm.  A.  Hammond,  M.  D.  "  '■' 

PHYSICIANS'  PERFECT  VISITING  LIST ,  ,o 

By  G,  Archie  Stockwell,  M.D.                                           •  •  • .     • .  ju 
A  NEW  TREATMENT  OF  CHRONIC  METRITIS .o 

By  Dr.  Georges  Apostoll.  ' 

CLINICAL  THERAPEUTICS .  oo 

By  DujardinBeaumeiz,  M.  D. 
MICROSCOPICAL  DIAGNOSIS ,  „„ 

By  Prof.  Chaa.  H.  Stowell,  M.S.  

PALATABLE  PRESCRIBING ,  no 

By  B.  W.  Palmer,  A.  M,  M.  D.  

UKTOWARD  EFFECTS  OF  DRUGS ,00 

By  L.  Lewin,  M.  D.  

SANITARY  SUGGESTIONS  (Paper) -, 

By  B.  W.  Palmer,  M.  D.  ' 

SELECT  EXTRA-TROPICAL  PLANTS ,00 

By  Baron  Ferd.  von  Muller,  

TABLES  FOR  DOCTOR  AND  DRUGGIST a  qo 

By  Ell  H.  Long,  M.  D.  *^ 


GBORGE    S.   DAVIS,  Publisher, 

O.  Soac  -a-ro  Detroit,  Iw^lcl*.. 


■J 

■i 


^■^-XK, 


^IQ-^m 


i5^S»-J£J£teiB3ft«ii;^ . 


m 


<5) 


a^cr 


i^im^mm^mm'jiiiiU'^Mammsmkma 


^&^.^%£?i:.ta 


